Pediatric Scoliosis

The Role of Imaging in the Evaluation of Scoliosis in a Pediatric Patient: 

The Role of Imaging in the Evaluation of Scoliosis in a Pediatric Patient Tad Landry Jennifer Langhart Jaimie Molbert February 12, 2012

What is Scoliosis: 

What is Scoliosis Scoliosis is an abnormal curvature of the spine. Can occur in the mediolateral or anteroposterior directions Mediolateral : the curvature is named right or left based on the side of the convexity Anteroposterior : the curvature is referred to as kyphotic or lordotic

Incidence: 

Incidence Scoliosis affects approximately 2% of the population I ncreases likelihood to 20% if present in family history In a study by Rogala et. al, data was obtained on 1,122 students with idiopathic scoliosis I ncidence = 4.5 percent F emale-to-male ratio = 1.25:1.0 over-all Ratio varied directly with the severity of the curve 1:1 for curves of 6 to 10 degrees 5.4:1 for curves of more than 20 degrees.

Types of Scoliosis: 

Types of Scoliosis Several types are defined by the etiology and age at which the scoliosis begins Non-structural scoliosis - a reversible lateral curvature of the spine without rotation Reversable by correcting the underlying cause Structural or idiopathic scoliosis - an irreversible lateral curvature of the spine with rotation Most common type Present in approximately .05% of the population 85% of all scoliosis cases are idiopathic in nature Three types: infantile, juvenile, and adolescent The most common type is a right thoracic scoliosis in adolescent girls

Types of Scoliosis: 

Types of Scoliosis N euromuscular scoliosis - bones of the spine either fail to form completely or fail to separate from each other during fetal development. Develops in people with other disorders, such as birth defects, muscular dystrophy, cerebral palsy, or Marfan’s disease. Degenerative scoliosis - caused by changes in the spine due to arthritis known as spondylosis Occurs in older adults Caused by weakening of the ligaments and soft tissues and presence of bone spurs Can also be affected by osteoporosis, vertebral compression fractures, and disc degeneration

Compensated vs. Decompensated: 

Compensated vs. Decompensated Compensated scoliosis – shoulders are in line with pelvis due to compensations in the spine above and below the abnormality Decompensated scoliosis – a lateral shift is present due to the abnormality being greater than the curves above and below

Diagnosis: 

Diagnosis Diagnosis varies according to the etiology of the abnormal curvature For the purposes of this presentation the diagnosis, prognosis, and impact of function will be discussed for the most common type, idiopathic scoliosis. Idiopathic scoliosis begins slowly, insidiously, and painlessly. Typically progresses to 30 degree curvature before detection in the clinic

Physical Examination: 

Physical Examination Complete physical examination is necessary to exclude other causes of scoliosis School screenings are beneficial for early detection to decrease severity and possible surgical intervention Radiographic examination plays an important role in the diagnosis of scoliosis and will be further discussed later in the presentation

Prognosis: 

Prognosis The amount of growth remaining in a child is important because the deformity of scoliosis increases with growth The more severe a curvature is the more likely that it will increase

Treatment: 

Treatment C hildren with curves of 20 to 40 degrees and two years or more of expected skeletal growth, bracing can prevent worsening of curve and possibly correct the existing abnormality A thoracolumbosacral orthosis , Boston brace, and Milwaukee brace are the most commonly used. Curvature more than 40 degrees and possibility of deformity is best treated surgically by internal spinal instrumentation and spinal fusion Usually deferred until 10 years of age

Role of Imaging: 

Role of Imaging Imaging in scoliosis is used to determine: Etiology Size, site, and flexibility of curve Skeletal maturity Observe progression or regression of curve Cobb method to determine the severity of the curve: Lines are drawn on the image using the most cephalic and caudal vertebrae of the curve that are angled the most toward the concavity as reference points Lines are drawn perpendicular to these reference lines, and the point at which they intersect is noted The angle at which the lines intersect is measured, and this determines the degree of the curvature

Imaging Choices: Conventional Radiograph: 

Imaging Choices: Conventional Radiograph A conventional radiograph (x-ray) is best utilized with the patient in standing. Several uses are that it can: Measure curvature angles Greater than 10 degrees is diagnosed as scoliosis Grade the deformity Assess progression or improvement Follow-up and assessment of hardware In pediatrics, used to assess congenital abnormalities of the spine effecting the curvature Also able to provide pre-operative and prognostic information Stress or lateral side bending views are best for this option.

Imaging Choices: MRI and CT: 

Imaging Choices: MRI and CT CT and MRI can further assess congenital abnormalities of the vertebral bodies Observe changes in the spine or spinal cord caused by abnormal stresses placed on it Premature or severe degenerative changes Presence of a syrinx , which is a cyst in the spinal cord Tethered spinal cord due to abnormal attachment to bone Examine possible changes in the central canal and lateral foramen An MRI is typically preferred in the pediatric patient to minimize radiation exposure A con is that it requires anesthesia to decrease movement during testing

Radiograph: 

Radiograph The image to the left is an AP view of a 13-year-old girl with scoliosis Alignment: Left convex thoracic scoliosis with 57° Cobb measurement Ribs compressed on right, expanded spacing on left Bone Density: Unremarkable Cartilage: Decreased intervertebral disc space at T2-T5 Increased intervertebral disc space on left (concave) versus right (convex) side Soft Tissue: Narrowing of diaphragm

MRI: 

MRI The image to the left is a T2 MRI image Alignment: Left convex thoracic curvature Possible right rotation at approximately T6-T12 Bone Density: Normal throughout Cartilage: Nucleus Pulposus deviated left or right depending point of curvature Soft Tissue: Possible syrinx at approximately T8-T9 Fluid present over approximately T7-T9 Increased visibility of ligaments on right side of vertebral bodies secondary to rotation.

Possible Impairments: 

Possible Impairments Biomechanics: Decreased A/PROM, with decreased left SB, right rotation, flexion and extension Tight and weak musculature on the right; lengthened and weak musculature on the left Presence of rib hump on the convex side with forward bending Physical: Shortened intercostal space on the right Decreased cavity space leading to decreased cardiopulmonary function Diaphragm compressed Bowel issues Damage to spinal cord due to decreased canal space Fractures Herniated discs Abnormal osseous formation Decreased self- esteemdue to physical appearance Decreased ADLs and function

Questions: 

Questions If a patient presents with a non-structural scoliosis and the impairments mentioned above, what type of treatment would you expect to use in the clinic? What would you consider is the best age to start screening children for scoliosis? What would you tell a parent to look for when screening for scoliosis?

References: 

References Augustsson , H. (2012). Imaging for physical and occupational therapists . Informally published manuscript, University of St. Augustine for Health Sciences, St. Augustine, FL. Blanco, J. S., Green, D. W., & Widman , R. F. (2008, April 15). Interview by N. Novick [Personal Interview]. Scoliosis in the pediatric patient. Hospital for special surgery, New York, NY. , Retrieved from http://www.hss.edu/conditions_scoliosis-pediatric-patient.asp Gaillard, F. (Photographer). (2010). Levoscoliosis . [Web Photo]. Retrieved from http://radiopaedia.org/images/530293 Hospital for Special Surgery: Department of Radiology and Imaging. (2008, November 10). Imaging for scoliosis: An overview . Retrieved from http://www.hss.edu/conditions_scoliosis-imaging-overview.asp Rogala , E. J., Drummond, D. S., & Gurr , J. (1978). Scoliosis: Incidence and natural history. The Journal of Bone and Joint Surgery , 60-A (2), 173-176 . Salter, R. B. (1999). Disorders of epiphysis and epiphyseal growth. In E. Johnson (Ed.), Textbook of Disorders and Injuries of the Musculoskeletal System (pp. 365-372). Baltimore, MD: Lippincott Williams & Wilkins . Spinasanta , S. (Photographer). (2010). X-ray of 13 year old female with scoliosis . [Web Photo]. Retrieved from http://www.spineuniverse.com/exams-tests/rays-radiographs