SCOLIOSIS Presentation, assessment, types and Treatment, Management

Scoliosis is an abnormal curvature of the spine that can occur in childhood or adolescence. It involves lateral curvature in the coronal plane as well as spinal rotation in the axial plane. Scoliosis is classified as either structural or non-structural. Structural scoliosis is permanent and involves bony deformities, while non-structural scoliosis is temporary and only involves curvature. The most common type of scoliosis is idiopathic scoliosis, which develops in adolescence and accounts for 90% of scoliosis cases in children. Scoliosis is assessed using Cobb's angle measurement, Adam's forward bend test, and a scoliometer. Treatment may involve bracing or surgery depending on the severity

1. SCOLIOSIS Dr. Nitin Saini

2. CONTENTS :- Introduction Definition Epidemiology Anatomy Classification Pathology Diagnosis Examination Treatment Sign & Symptoms Risk Factors Aims Physiotherapist Management

3. Introductio n of SCOLIOSIS Scoliosis is the sideways curvature of the spine. Scoliosis is a side-to-side curve of your spine. A person with scoliosis will have a sideways  C or S-shaped curve in their spine. Scoliosis is an abnormal lateral curvature of the spine.

4. DEFINATION Scoliosis is defined by the  Cobb's angle  of spine curvature.  It is most often diagnosed in early childhood or adolescence. When viewed from the side there will normally be a slight round back ( kyphosis ) in the upper back and a mild swayback ( lordosis ) in the lower back.

5. It is triplanar deformity of spine which involves the following planes: Coronal Plane – Lateral Curvature Sagittal Plane – Kyphosis , Lordosis Axial Plane – Rotation The primary age of onset for scoliosis is 10-15 years old, occurring equally among both genders. Females are eight times more likely to progress to a curve magnitude that requires treatment. Scoliosis effect about 5 million people in India that is 0.4 % of the population the prevalence among children is much more higher. Epidemiology

6. Clinically Relevant Anatomy The vertebral column normally consists of 24 separate bony vertebrae, together with 5 fused vertebrae that form the sacrum, and usually, 4 fused vertebrae that form the coccyx 7  cervical  vertebrae 12  thoracic  vertebrae 5  lumbar  vertebrae.

7. CLASSIFICATION It is of two types: Non-structural (temporary) Structural (permanent) Non-structural scoliosis: This is a mobile or transient scoliosis. It has three subtypes, as discussed below: Postural scoliosis: It is the commonest overall type, often seen in adolescent girls. Compensatory scoliosis: In this type, the scoliosis is compensate for the tilt of the pelvis (e.g., in a hip disease or for a short leg). Sciatic scoliosis: This is as a result of unilateral painful spasm of the paraspinal muscles, as may occur in a case of prolapsed intervertebral disc.

8. Structural scoliosis: It is a scoliosis with a component of permanent deformity. The following are the different subtypes: Idiopathic Scoliosis: It is the commonest type of structural scoliosis. “Idiopathic” means the cause is unknown. Research does indicate that it runs in families and has a genetic (hereditary) link. Infantile scoliosis : Age 0-3 years. Juvenile scoliosis : Age 4-10 years. Adolescent scoliosis : Age 11-18 years. Adult idiopathic scoliosis : Diagnosed any time after age 18 when skeletal growth is complete .

9. 2. Congenital scoliosis:  This is a rare spine abnormality. It occurs when vertebrae (the bones that make up your spine) don’t form as they should during embryonic development. 3. Neuromuscular scoliosis: This type of scoliosis generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment. Abnormalities in the muscles and nerves. It usually happens alongside neurological (nerve) or muscular conditions like an Injury Cerebral Palsy Spina Bifida Muscular Dystrophy

10. PATHOLOGY The main pathology is lateral curvature of a part of the spine. This is called the primary curve. The spine above or below the primary curve undergoes compensatory curvature in the opposite direction. These are called the compensatory or secondary curves. The lateral curvature is associated with rotation of the vertebrae. In curves of the thoracic spine, rotation of the vertebrae leads to prominence of the rib cage on the convex side, giving rise to a rib hump.

11. Scoliosis is usually confirmed through a Physical Examination X-ray Spinal Radiograph CT Scan MRI DIAGNOSIS

12. Examination Adam’s Forward bend test Cobbs angle Scoliometer The Adam forward bend test can be used to make a distinction between structural scoliosis or non-structural scoliosis of the cervical to lumbar spine. Procedure: The test can be performed in the standing and sitting position. The patient needs to bend forward, starting at the waist until the back comes in the horizontal plane, with the feet together, arms hanging and the knees in extension. The examiner stands at the back of the patient and looks along the horizontal plane of the spine searching for abnormality of spine.

13. 2. The Cobb angle: is a standard measurement to determine and quantify the magnitude of spinal deformity specially to determine the progression of scoliosis. Procedure:  Locate the most tilted vertebra at the top of the curve and draw a parallel line to the superior vertebral end plate. Locate the most tilted vertebra at the bottom of the curve and draw a parallel line to the inferior vertebral end plate. Two additional lines are drawn at a 90-degree perpendicular angle to the first lines so they intersect. The angle formed between these two intersecting lines is a cobb’s angle.

14. 3..  The scoliometer  is an inclinometer designed to measure trunk asymmetry, or axial trunk rotation. It’s used at three areas: Upper thoracic (T3-T4) Middle thoracic (T5-T12) Thoraco -lumbar area (T12-L1 or L2-L3) If the measurement is equal to 0°, there is a symmetry at the particular level of the trunk. An asymmetry at the particular level of the trunk is found, if the scoliometer measurement is equal to any other value. If the sociometer measurement is more than 7 degree it is considered as abnormal.

15. TREATMENT Scoliosis treatments vary, depending on the size of the curve. Children who have very mild curves usually don't need any treatment at all, although they may need regular checkups to see if the curve is worsening as they grow. Bracing or surgery may be needed if the spinal curve is moderate or large. Factors to be considered include: Maturity.  If a child's bones have stopped growing, the risk of curve progression is low. That also means that braces have the most effect in children whose bones are still growing. Bone maturity can be checked with hand X-rays. Size of curve.  Larger curves are more likely to worsen with time. Gender:  Girls have a much higher risk of progression than do boys.

16. Braces A brace may be recommended by the doctor for children with moderate scoliosis whose bones are still growing. Although wearing a brace won't cure scoliosis or reverse the curvature. it will typically stop the curve from getting worse. Brace is shaped to fit the body and is composed of plastic. This brace goes under the arms, around the rib cage, lower back, and hips, and it is nearly undetectable under clothing. Eg Milwaukee brace.

17. Surgical Treatment Severe scoliosis typically progresses with time A specialist may suggest scoliosis surgery to reduce the severity of the spinal curve and prevent it from getting worse. The most common type of scoliosis surgery is spinal fusion. In spinal fusion two or more of the vertebrae are fused together, so they can't move independently. Pieces of bone or a bone-like material are placed between the vertebrae. Metal rods, hooks, screws, or wires typically hold that part of the spine straight and still while the old and new bone material fuses together. If the scoliosis is progressing rapidly at a young age, surgeons can install a rod that can adjust in length as the child grows. This growing rod is attached to the top and bottom sections of the spinal curvature and is usually lengthened every six months. Complications of spinal surgery may include bleeding, infection, pain, or nerve damage. Rarely, the bone fails to heal and another surgery may be needed.

18. Signs & Symptoms Signs & Symptoms of scoliosis may include: Uneven shoulders. Shoulder blades that stick out. Head that doesn’t center above your pelvis. Uneven waist. Elevated  hips . Constant leaning to one side. Uneven leg length. Back pain Leg pain, numbness or weakness. Core muscle weakness. Difficulty standing upright. Over time, you may notice: Height loss. Uneven alignment of your pelvis and hips. One side of the rib cage jutting forward.

19. Risk factors The risk factors for scoliosis include: Age:  Signs and symptoms often start during a growth spurt just before puberty. Gender:  Females have a higher risk of scoliosis than males. Genetics:  People with scoliosis often have a close relative with the condition. Complications Of Scoliosis Without treatment, severe cases of scoliosis can lead to: Long-lasting pain. Physical deformity. Organ damage. Nerve damage Arthritis Spinal fluid leakage Difficulty breathing.

20. Aims The aims of physical therapy are:  Autocorrection 3D Coordination Equilibrium Ergonomical corrections Muscular endurance/ strength Neuromotor control of the spine Increase of ROM Respiratory capacity/ education Side-shift Stabilization

21. Physical Therapy Management To manage scoliosis work in three planes: the sagittal , frontal and transverse. [15] Conservative therapy consists of: physical exercises bracing manipulation electrical stimulation Insoles The  physical therapist  has three important tasks: Inform, Advise Instruct Important to do the correct exercises Inform the patient &/or parents about his/her situation.

22. T h a n k s !