Idiopathic adolescent scoliosis is 10 to 20 years and females are affected six times more as compared to boys. In idiopathic adolescent scoliosis,right thoracic curve is more predominant. There is a low risk of cardiovascular compromise and overall risk of progression is 23%.
The characteristics of idiopathic adolescent scoliosis is a three-dimensional deformity of the spine with lateral curvature plus rotation of the vertebral bodies.
Cause of Idiopathic Adolescent Scoliosis
Lately, the researchers have pointed a multifactorial causation of idiopathic adolescent scoliosis that include following
- Genetic predisposition
- Connective tissue abnormality
- Neurophysilogical disposition
- Abnormal biomechanical forces
Curve Progression in Idiopathic Adolescent Scoliosis
Less than 10% of children with curves of 10 degrees or more require treatment. What is more important is probability of the curve progression. Progression is defined as an increase of 5 degrees or more measured by the Cobb angle over two or more visits.
Following factors have been found to be related to curve progression in idiopathic adolescent scoliosis
- Progression is more likely in girls than in boys.
- There is progression risk associated with the rapid adolescent growth spurt before the onset of menses. The incidence of progression decreases as the child gets older.
- A Risser Sign of has higher risk for progression than Risser signs of 3 or 4.
- Double curves are more likely to progress than single curves
- Single thoracic curves tend to be more progressive than single lumbar curves.
- More severe curves have a higher progression
The effect of progressive curves on adults are
- Back pain
- Pulmonary function [affected only in patents with thoracic curves and there is a direct correlation was between decreasing vital capacity and increasing curve severity.]
- Psychosocial effects
- Mortality (usually in thoracic curves >100 degrees)
Diagnosis of Idiopathic Adolescent Scoliosis
The evaluation begins with a thorough history and is followed by complete physical examination and neurological examination. This is followed by radiographic evaluation.
In physical examination, after the general physical examination, the spine is examined and characteristics of the deformity are recorded.
The height of the patient while standing and while sitting should be measured and recorded. These measurements can be compared with future measurements in follow up to determine changes in the patient’s total height and whether any change is caused by growth of the lower extremities or by an increase or a decrease in the height of the trunk.
A detailed physical and neurological examination would help to rule out any neoplasm or a neurological disorder as the cause of scoliosis.
Radiographic Evaluation in Idiopathic Adolescent Scoliosis
Posteroanterior and lateral radiographs of the spine with patient in standing position are made and should also include iliac crest iliac crest distally and most of the cervical spine proximally. The use of posteroanterior view in comparison to anteroposterior view lessens the radiation dose to maturing breasts which sustain the most at risk from radiation
If patient is being considered for surgery a right and left bending films usually are obtained.
Due to vertebral rotation in scoliosis, standard anteroposterior views of scoliosis curves significantly underestimate the magnitude of the curve and also give the erroneous impression of kyphosis. Stagnara radiographic technique eliminate this rotational component of the curve , allowing a much more accurate measurement of the curve size and better evaluation of vertebral anatomy.
In this technique, an oblique radiograph is made with the cassette parallel to the medial aspect of the rotational rib prominence and the x-ray beam positioned at right angles to the cassette. This provides modified posteroanterior view. A film made at 90 degrees to this provides the true lateral view.
For assessing the skeletal maturity, the most common is assessment of bone age at the hand and wrist or Risser sign.
MRI of the whole spine is required for assessment if there is an unusual curve, a very rapid progression and a very large curve at presentation.
Treatment For Adolescent Idiopathic Scoliosis
The two most widely accepted and used methods in management of scoliosis nonoperative methods for idiopathic scoliosis are observation and bracing.
Observation is the primary treatment of all curves. Few degree of scoliosis is frequent in the population and most of these do not require a treatment. Only the progressive curves would require treatment. There is no definitive method Unfortunately, no method is reliable for accurately predicting at the initial evaluation for progression of the curve.
Therefore, periodic evaluation of the spine with radiographs still is necessary.
- Young patients with less than 20 degrees can be examined every 6 to 12 months.
- Adolescents with larger degrees of curvature should be examined every 3 to 4 months.
- Skeletally mature patients with curves of less than 20 degrees generally do not require further evaluation.
Depending on type of curve and age of the patient, furthrer treatment options are considered
- If progression of the curve (an increase of 5 degrees during 6 months) beyond 25 degrees is noted – orthotic treatment is considered.
- For curves of 30 to 40 degrees in a skeletally immature patient, orthotic treatment is recommended at the initial evaluation.
- Curves of 30 to 40 degrees in skeletally mature patients generally do not require treatment, but there being a potential for progression, these patients should be observed with yearly for 2-3 years after skeletal maturity, then every 5 years for life.
Orthotic treatment of adolescent idiopathic scoliosis is indicated in following situations
- A flexible curve of 20 to 30 degrees in a growing child with documented progression of 5 degrees or more.
- Curves in children between the 30 to 40 degree range at the initial evaluation. Although surgery usually is indicated for curves in the 40- to 50-degree range in growing children, orthotic treatment may be considered for some curves, such as a cosmetically acceptable double major curve of 40 to 45 degrees. Orthotic treatment is not used in patients with curves of more than 50 degrees.
Initially, the orthoses were to be worn 23 hours a day at least. Due to poor compliance, newer and more patient friendlyeen introduced which require wearing for 16 hours only and obviate the need for wearing the brace to the school. regimes have . If the curve is less than 35 degrees and does not show significant vertebral wedging, part-time brace wear is certainly reasonable to attempt first. if the curve progresses in spite of it, full-time bracing can be started.
The Charleston and Boston braces are frequently used braces for scoliosis.
Operative Treatment of Adolescent Idiopathic Scoliosis
The goals of surgery for spinal deformity are
- To correct or to improve the deformity
- Maintain sagittal balance
- To preserve or to improve pulmonary function
- To minimize morbidity or pain
- To maximize postoperative function
- Improve or maintain the function of the lumbar spine.
The operative treatment of scoliosis aims at correction of the deformity and is mot meant for every scoliotic curve. Most of the surgeries are indicated if there are potential consequences of significant deformity and pain.
In children and adolescents, surgery is considered if the curve can be expected to become troublesome in adulthood.
Following are common indications for surgery in Idiopathic adolescent scoliosis
- A progressive curve despite non operative treatment
- Severe deformity (>50 degrees) and asymmetry of trunk in adolescent
- Pain not relieved by nonoperative treatment
- Thoracic lordosis – Thoracic lordosis has a detrimental effect on pulmonary function, and bracing worsens thoracic lordosis.
- Significant cosmetic deformity
Surgery is indicated more in single curves than double curves as double curves are cosmetically more acceptable.
The surgical techniques may include anterior, posterior, or combined anterior and posterior procedures.
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