SCOLIOSIS

• It is a postural deformity of the spine resulting

in a lateral deviation or curve.

• Scoliosis is commonly associated with rotation

of the vertebral bodies located within the
curve.
 Classification of Scoliosis

• Idiopathic
– Infantile (0 to 3 years old)

– Progressive

– Juvenile (4 years to puberty onset)

– Adolescent (puberty onset to epiphyseal closure)

– Adult (after epiphyseal closure)

• Neuromuscular

– Neuropathic
– Upper motor neuron lesion
• Cerebral palsy
– Spinocerebellar degeneration
• Friedreich's ataxia
– Syringomyelia
– Spinal cord trauma or tumor
– Lower motor neuron lesion

• Poliomyelitis
• Spinal muscular atrophy
• Amyotrophic lateral sclerosis
• Charcot-Marie-Tooth
• Myelomeningocele

– Myopathic

• Arthrogryposis
• Muscular dystrophy
– Duchenne
– Limb-girdle
– Fascioscapulohumeral
• Congenital hypotonia
• Myotonic dystrophy
• Congenital
– Congenital scoliosis
• Failure of formation
• Wedge vertebra
• Hemivertebra
• Failure of segmentation
• Unilateral bar
• Bilateral bar
• Mixed
– Associated with neural tube defects
• Myelomeningocele
• Meningocele
• Spinal dysraphism
– Other
• Neurofibromatosis

• Traumatic
– Fracture and/or dislocation
– Postradiation therapy

• Soft-tissue contractures
– Postempyema
– Burns
– Other
• Osteochondrodystrophies

• Tumor
– Benign
– Malignant

• Rheumatic diseases

• Metabolic
– Rickets
– Juvenile osteoporosis
• Related to lumbosacral dysfunction
– Spondylolysis
– Spondylolisthesis
– Other
• Thoracogenic
– Postthoracoplasty
– Postthoracotomy
– Other
• Hysterical
• Functional
– Postural
– Due to leg length discrepancy
– Due to muscle spasm
• Scoliosis can result from congenital, degenerative,
disease-related, or idiopathic causes.

• The curve itself often does not produce symptoms or

complaints, particularly a curve that does not exceed
20 degrees.

• When scoliosis is severe, pain and cosmetic

deformities occur.
• Classification of the Curve – According to the
convexity of the curve.

– C shaped or S- shaped curve

– S- shaped is usually compensatory

• Scoliosis generally progresses during growth

spurts.
• Deformity such as

– Humping of the back

– Asymmetric shoulder or hip height

– Asymmetry of waist contour

– All may produce psychosocial symptoms such as low self-

esteem, anxiety, and depression.
• Curves that exceed 60 degrees begin to affect other
systems.

– They can produce shortness of breath due to restrictive

lung disease

– Weakness, pain, paresthesia; or hypesthesia due to

compression or impingement of nerve roots

– Impaired activity tolerance due to increased energy costs

for maintaining trunk stability.
 Physical Examination
• Minor curves are difficult to detect on inspection of
the patient.

• An easy way to detect a subtle thoracic or lumbar

curve is to drop a plumb line from the occiput, or C7
spinous process, and inspect the spine for lateral
deviations from this line.
• Have the patient bend forward, because the rotation
associated with scoliosis is most easily seen in the
forward flexed position.

• Asymmetry of the back contour in this position is due

to vertebral body or rib rotation and may be
quantified.
 Adam’s forward bend test

For this test, the patient is asked to lean forward with

his or her feet together and bend 90 degrees at the
waist. The examiner can then easily view from this
angle any asymmetry of the trunk or any abnormal
spinal curvatures.
• Asymmetry of the waist fold contour, or unequal iliac
crest and shoulder height.

• Scoliosis should be suspected when café au lait spots

(often associated with neurofibromatosis) or a leg-
length discrepancy exceeding 2.2 cm is present.
• Thorough serial assessments are advisable every 6 to
12 months.

• These assessments usually include x-rays and should

focus on the degree of curvature, location and extent
of the curve, degree of rotation, degree of skeletal
maturity, correctibility of the curve, height, vital
capacity and pulmonary function tests.
 Scoliometer
An inclinometer (Scoliometer) measures
distortions of the torso.
• The patient bends over, arms dangling
and palms pressed together, until a
curve can be observed in the upper
back (thoracic area).
• The Scoliometer is placed on the back
and measures the apex (the highest
point) of the upper back curve.
• The patient continues bending until the
curve can be seen in the lower back
(lumbar area). The apex of this curve is
also measured.
• Patients with degenerative scoliosis should be
examined for neurologic deficits.

• Lower extremity strength, sensation, and reflexes

should also be checked when the curvature exceeds
40 degrees or when the patient complains of
weakness, paresthesias, or decreased sensation
regardless of the etiology of the scoliosis.
 Diagnostic Studies

• Standing anteroposterior (AP) and lateral x-rays are

useful in the evaluation of scoliosis .

• X-rays can reveal congenital abnormalities of the

vertebral body that cause spinal imbalance (block,
bar, butterfly vertebrae), evidence of Scheuermann's
disease (endplate fluting), or the lateral vertebral
body wedging that is characteristic of idiopathic
scoliosis.
• Measurement of the scoliotic curve on plain films is
done by either the Cobb or Risser method.

• The most common measurement, the Cobb angle, is

determined by the intersection of two lines drawn
perpendicular to the vertebral endplates that represent
the maximal deviation of the spine
Risser’s sign
Moe – Nash
classification
of spinal
rotation
 Treatment
• Preventive measures

– Early detection. Ideally a screening programme of all

children between age group of 10-14 years is necessary.

– Education of parents may be helpful.

– Conservative treatment is indicated in growing children

with curve less than 40 degrees.
 Referral Guidelines & Treatment

Curve (degrees) Risser grade X-ray/refer Treatment

10 to 19 0 to 1 Every 6 months/no Observe

10 to 19 2 to 4 Every 6 months/no Observe

20 to 29 0 to 1 Every 6 months/yes Brace after 25 degrees

20 to 29 2 to 4 Every 6 months/yes Observe or brace *

29 to 40 0 to 1 Refer Brace

29 to 40 2 to 4 Refer Brace

>40 0 to 4 Refer Surgery †

 Treatment
• Initial
– In all patients, regardless of age, it is important to
identify curves that are likely to be progressive.

– In general, scoliotic curves less than 20 degrees

are observed through serial assessment.

– NSAIDs or analgesics may be used for pain

management. Transcutaneous electrical nerve
stimulation (TENS) may also be used to manage
pain.
• Rehabilitation
– Exercise is beneficial for general well-being,
flexibility, and to improve posture.

– Bracing is an important part of the rehabilitation

intervention.

– The goal of orthotic treatment is to reduce pain and

limit progression of the curve. The most common
brace selection is a body jacket
thoracolumbosacral orthosis (TLSO) such as the
Boston or Denver brace.
Boston Brace
– High thoracic and cervical curves may require a
Milwaukee cervicothoracolumbosacral orthosis
(CTLSO).

– Bracing for idiopathic curves in a growing child or

adolescent is maintained until spinal growth
centers fuse.

– When a TLSO body jacket or corset is used to

decrease pain and improve posture for patients
with degenerative scoliosis, wear time depends on
symptoms
Milwaukee Brace
 Mild Postural curve (<40 degrees)
• Active correction

• Passive correction – Hanging

• Maintainence of Correction
 Management of Postural Scoliosis
• Progressive re-education of bad posture
• Patient is trained to feel and hold correct posture.
Postures should be corrected passively by the
therapists.
• General mobility exercises for spine
• Deep breathing exercises
• Stretching of the tight tissues
• Advice for continous exercises and avoiding
positions and activites prone to produce bad posture.
Exercises (Stretching)
Strengthening
Chest mobility exercises
Other Exercises
Management of Structural Scoliosis
• It is necessary to apply Milwaukee or Boston brace to
prevent deterioration of curve and to maintain
correction with active exercises.
• Mobility exercises
• Deep breathing exercises
• Lumbar lordosis should be corrected.
• Stretching of tight structures.
• The brace needs repeated adjustments as the child
grows. It is continued till child attains the age of
skeletal maturity. It can be weaned off gradually
thereafter.
• The brace needs to be worn day and night except
during sessions of exercises.
 Severe Structural Scoliosis
• If the curve is >40 degrees than surgical intervention
is needed.
• Pre-operative Physiotherapy –
– Assessment of vital parameters, rib hump,pulmonary
function, muscle charting, neurological examination, gait
analysis.
– Teach ankle toe movement, isometrics exercises.
– Postural correction
– Spinal stretching and mobility exercises
• Indications for surgery :-

– Cord Compression

– Pain

– Respiratory impairments

– Cosmetic
• Basic principles of surgical treatment –

– Correction of the curve

– Maintainence of the correction achieved by spinal

instrumentation and/or spinal fusion.
• Aims of treatment of scoliosis :-

– To restore symmetry of the trunk as much as possible by

correction of the curve.

– To straighten thoracic curves to stop the deterioration in

the pulmonary functions.
• Correction of the curve –

– Turnbuckle cast technique

– Distraction technique

• Maintenance of the correction achieved –

– Spinal fusion
– Spinal instrumentation
• Spinal fusion –

– After spinal fusion, a plaster jacket is applied which is

maintained for about 6 months till the fusion consolidates.

• Spinal instrumentation –

– Harrington’s Instrumentation
– Luque Instrumentation
– Dwyer’s Instrumentation
– Zielke Instrumentation
Spinal Fusion
Harrington’s Rod
Luque’s Instrumentation
Zielke’s Instrumentation
• Post-operative Physiotherapy :-

• Initial days :-
– Respiratory care
– Ankle toe movements
– Active movements of upper limbs and lower limbs.
– Positioning and turning.

• After 5 days :-
– Sitting, standing and walking with brace can be started.
– Mobility exercises
• Specific points to remember –

– In one level anterior fusion – exercises for back is not

advised, except isometrics. Exercises are begun after 3
months of surgery,

– In two level anterior fusion – period of POP is 3-6 months.

– Harrington’s rod – log rolling is taught. POP jacket worn

for 6 months. ADLs can be done with jacket on.
• Postsurgical Complications –
– Deep vein thrombosis
– Pulmonary embolism
– Paralytic ileus
– Associated stiffness of neck, shoulder.
– Wound infection
– Plaster sores.