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Scoliosis (from Greek: skolisis meaning from skolios, "crooked")[1] is a medical condition in which a person's spine is curved from side to side Lateral curvature of the spine >10 accompanied by vertebral rotation.
[1]. Online Etymology Dictionary. Douglas Harper, Historian. Accessed 27 December 2008. Dictionary.com
Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile [2].
Classification and Terminology. In Moe's Textbook of Scoliosis and Other Spinal Deformities 3rd edition. Philadelphia Saunders; Winter RB 2002:39-43.
Types:
STRUCTURAL SCOLIOSIS
Congenital
Degenerative
Others
Neurofibromatosis
Following empyema Extraspinal contractures Following burns Infections of bone Rickets Metabolic disorders Osteogenesis imperfecta Marfans Syndrome Mesenchymal disorders Ehlers-Danlos Syndrome
NON-STRUCTURAL SCOLIOSIS
Terminology Committee. Scoliosis Research Society: A glossary of scoliosis terms. Spine 1:57- 58, 1976
Etiology:
GENETIC FACTORS: Harrington studied women with a scoliotic curve that exceeded 15 and found a 27 percent prevalence of scoliosis among their daughters.[1] EFFECTS OF CONNECTIVE TISSUE: Changes in the distribution of collagen in patients with IS differ from those of seen in subjects without IS, but these changes are not consistent among those with IS.[2] Elastic fiber abnormalities in the spinal ligaments have also been reported in a substantial number of patients with IS compared with those of individuals without IS.[3]
[1]. Harrington PR. The etiology of IS. Clin Orthop 1977;126:17-25. [2]. Echenne B, Barneon G, Pages M, et al. Skin elastic fiber pathology and IS. J Pediatr Orthop 1988;8:522-528. [3]. Hadley-Miller N, Mims B, Milewicz DM. The potential role of the elastic fiber system in adolescent IS. J Bone Joint Surg [Am] 1994;76:1193-1206.
The differences between type I (slow-twitch) and type II (fasttwitch) muscle fibers in those with IS have been studied. Decreased type II fibers in the paraspinous and gluteus medius muscles have been reported. Sahgal V, Shah A, Flanagan, N, et al. Morphologic and morphometric studies of muscle in IS. Acta orthopaedica Scandinavica, 1983;54:242-251.
Spencer GS, Eccles MJ. Spinal muscle in scoliosis. Part 2. The proportion and size of type 1 and type 2 skeletal muscle fibres measured using a computer-controlled microscope. Journal of Neurological Science 1976;30:143-154.
Another article reported a normal distribution of Type I and type II fibers on the convexity of the curve, but a lower frequency of Type I fibers on the concavity.
Bylund P, Jansson E, Dahlberg E, et al. Muscle fiber types in thoracic erector spinae muscles. Fiber types in idiopathic and other forms of scoliosis. Clinical Orthopaedics 1987;214:222-228.
Another article showed a decrease in the number and size of type II fibers, with no preference for the convex or concave side.
Slager UT, Hsu JD. Morphometry and pathology of the paraspinous muscles in IS. Developmental Medicine & Child Neurology. 1986;28:749-756.
Another study found similar results of decrease in the number and size of type II fibers from distant muscle sites (deltoid, trapezius, gluteus, and quadriceps)
Yarom R, Robin GC, Gorodetsky R. X-ray fluorescence analysis of muscles in scoliosis. Spine 1978;3:142-145.
CONCLUSION: A myopathic process may play a significant role in the etiology of IS.
An imbalance of growth that appears to exist between the anterior and posterior structures of the spine has been hypothesized as a contributing factor to the etiology of IS.
It is suggested the anterior structures grow more rapidly than the posterior ones, in effect forcing the spine to rotate to the side upon forward bending.
Dickson RA, Lawton JO, Archer IA, et al. The pathogenesis of IS. Biplanar spinal asymmetry. Journal of Bone & Joint Surgery, 1984;66:8-15.
70 patients with thoracic curves taken Average Cobb angle was 39 with an average kyphosis of 20, as measured by a simple standing lateral radiographs. However, a"true" lateral of the apical vertebrae of the thoracic curve could be viewed, by taking into account the vertebral rotation associated with the curve, average lordosis of 3 was noted. the apical one or two vertebrae were distinctly wedged, anterior height greater than the posterior height Thus, Dickson et al. argued the coronal plane curvature as seen in IS is entirely secondary to the sagittal plane imbalance of growth.
Diagnosis:
Diagnosis is made by physical examination Extent is often underestimated until radiographs are visualized. Degree of spinal deformity is the most important risk factor for respiratory failure, and the effects of kyphosis and scoliosis are additive.
Scoliosis Screening
Cobb Angle:
The Cobb angle, named after the American orthopedic surgeon John Robert Cobb (1903-1967) Originally used to measure coronal plane deformity on antero-posterior plain radiographs in the classification of scoliosis. Cobb angle is defined as the angle formed between a line drawn parallel to the superior endplate of one vertebra above the fracture and a line drawn parallel to the inferior endplate of the vertebra one level below the fracture.
The Cobb angle is the preferred method of measuring scoliosis and posttraumatic kyphosis in a recent metaanalysis of traumatic spine fracture classifications.
Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, Kwon B, Rampersaud R, Bono C, France J, Dvorak M. Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group. Spine. 2006 Mar 1;31(5):E156-65.
All of the Cobb angle prognostic assumptions are based off a single study by Lonstein and Carlson in 1984, which has never been repeated or reproduced to this very day, according to Stitzel.
Dr Stitzel Lititz, Pennsylvania, United States Is Cobb angle an obstacle to the future progress in scoliosis treatment?
Sonia Pineda, Juan Bago, Carmen Gilperez and Jose M Climent. Validity of the Walter Reed Visual Assessment Scale to measure subjective perception of spine deformity in patients with idiopathic scoliosis. BioMed Central Published: 08 November 2006 Scoliosis 2006, 1:18 doi:10.1186/1748-7161-1-18
The SRS-22 is a disease-specific instrument capacity to demonstrate change in health status more effectively than the SF-12 and in more domains than the Oswestry Test/retest reliability was excellent.
Bridwell, Keith H. MD; Cats-Baril, William PhD; Harrast, John; Berven, Sigurd MD; Glassman, Steven MD; Farcy, Jean-Pierre MD; Horton, William C. MD; Lenke, Lawrence G. MD; Baldus, Christine RN; Radake, Terri RN The Validity of the SRS-22 Instrument in an Adult Spinal Deformity Population Compared With the Oswestry and SF-12: A Study of Response Distribution, Concurrent Validity, Internal Consistency, and Reliability Spine: 15 February 2005 - Volume 30 - Issue 4 - pp 455-461
Prognosis:
Mild disease has a good prognosis and requires supportive care only. Adolescents- both surgery and brace treatment improve lung function. Adults- surgery is of questionable benefit and carries a significant complication rate. Medical therapy can include pulmonary rehabilitation, supplemental oxygen as needed, and managing ventilatory failure.
TREATMENT :
Idiopathic Scoliosis:
Infantile scoliosis:
Curve may disappear by itself with increasing age Well-applied body cast, under anesthesia, regularly reapplied until maximum correction Milwaukee brace full time (23hrs a day) preferable to TLSO- circumferential nature, can reduce pulmonary functions by creating a tubular thorax Surgical correction
Instrumentation without fusion Fusion of curve
Juvenile idiopathic scoliosis: Milwaukee brace- worn full time for 18-24 months With reduction in curve, time of wearing the brace reduced from 20 hours to 6 hours everyday. Surgery:
Instrumentation without fusion Definite fusion(anterior and posterior approaches)
Milwaukee brace
SpineCor Brace
Is the first and only truly dynamic brace, which provides a progressive correction of Idiopathic Scoliosis from 15 Cobb angle and above. Preserves normal body movement and growth and allows normal activities of daily living.
Carol C. Hasler, Stephanie Wietlisbach, Philippe Buchler. Objective compliance of adolescent girls with idiopathic scoliosis in a dynamic SpineCor brace. Journal of Child Orthopaedics (2010) 4:211218 The current study showed that the compliance of patients in a dynamic SpineCor is as limited as in a conventional brace.
First section the pelvic base (1), the crotch bands (2) and the thigh bands (3).
Second section
the bolero (4) and the corrective elastic bands (5).
Chneau Brace
The objectives of the Chneau brace are to obtain a three-dimensional correction of the scoliotic deformity, with emphasis not only on the coronal and transverse planes, but also on the sagittal plane.
THORACIC SECTION
LUMBAR SECTION
PELVIC SECTION
TRANSVERSAL DEFORMITIES
79 patients (58 girls and 21 boys) with progressive idiopathic scoliosis, with initial Cobb angle between 20 and 45 degrees. Treated with Chneau brace and physiotherapy
Conservative treatment with Chneau orthosis and physiotherapy was effective in halting scoliosis progression in 48.1% of patients.
Katarzyna Zaborowska-Sapeta, Ireneusz M Kowalski, Tomasz Kotwicki, Halina Protasiewicz-Fadowska, Wojciech Kiebzk4 Effectiveness of Chneau brace treatment for idiopathic scoliosis: prospective study in 79 patients followed to skeletal maturity Scoliosis 2011, 6:2
Instrumentation:
HARRINGTON instrumentation- with fusion or without fusion HARRINGTON instrumentation with Luque wiring WISCONSIN procedure LUQUE system
Two great advantages in using Harringtons instruments. Firstly, a powerful corrective force can be applied without pressure on the skin ; and secondly, the time that the patient has to remain in hospital is considerably reduced.
C. R. BERKIN, HULL, ENGLAND HARRINGTONS INSTRUMENTATION AS A SALVAGE PROCEDURE FOR PSEUDARTHROSES IN SPINE FUSIONS FOR SCOLIOSIS Journal of Bone and Joint Surgery VOL. 50 B, NO. 3, AUGUST 1968
Patients with segmentation failures should be treated surgically as early as possible, according to the rate of deformity formation and certainly before pubertal growth spurt to try to avoid cor pulmonale.
Angelos Kaspiris, Theodoros B Grivas, Hans-Rudolf Weiss and Deborah Turnbull Surgical and conservative treatment of patients with congenital scoliosis: a search for long-term results. Scoliosis 2011, 6:12
92.9% of the patients are active in professional life or household 82.1% are actively engaged in sports activities the cosmetic appearance was rated in 87.7% the average correction of the scoliotic deformity in the frontal plain was 50.6%. CONCLUSION: The operative technique according to Harrington provides satisfactory results in idiopathic scoliosis after 2030 year followup.
D. Grob, M.D.,M. Rasmus, M.D., Thomas Egloff, M.D. Idiopathic Scoliosis Treated with Harrington Instrumentation - A Long-Term Follow-Up.
Wisconsin segmental spinal instrumentation safely achieves the objectives of partial correction, arthrodesis, and early return to function. Complications of the procedure included two wound infections (one superficial, one deep), one rod displacement, and two wire breakages. No pseudarthroses or neurologic complications were identified in this series.
Jeng CL, Sponseller PD, Tolo VT Outcome of Wisconsin instrumentation in idiopathic scoliosis. Minimum 5-year follow-up. Spine (Phila Pa 1976). 1993 Sep 15;18(12):1584-90
In all groups, the use of derotational instrumentation increased correction (37% Wisconsin vs. 24.5% HarringtonLuque) and decreased loss of correction (5% HarringtonLuque vs. 28% Wisconsin). Rates of neurological complications were similar in all groups; no persistent deficits were note Anterior release with halo traction and posterior fusion is the optimal treatment of severe scoliosis.
Potaczek T, Jasiewicz B, Tesiorowski M, Zarzycki D, Szczeniak A Treatment of idiopathic scoliosis exceeding 100 degrees - comparison of different surgical techniques. Orthopedic & Traumatology Rehabilitation. 2009 Nov-Dec;11(6):485-94.
Exercises:
Exercises to be done while wearing the brace
Pelvic tilts:
Push-ups
Sit-ups
Hamstrings stretch
Bicycle
Back strengthening
Side stretch
Abs strengthening
the muscles of the convexity having stronger contraction. Isokinetic exercises better than isometric exercises in treating scoliosis, because Isokinetic exercise may trigger more motor units to act together than isometric exercise. EMG activities of the thoracic muscle were significantly higher on the nondominant(concave) side than on the dominant (convex) side. This phenomenon suggests that compensated muscle activity may be needed for larger curve scoliosis when doing resistance exercise. Recommendation: more midback protection for large curves scoliosis when they are doing resistance exercises.
Yi-Ta Tsai, MD; Chau-Peng Leong, MD; Yu-Chi Huang, MD; Shih-Hua Kuo, MD; HoCheng Wang1, MD; Hsiang-Chun Yeh, BS; Yiu-Chung Lau, MD The Electromyographic Responses of Paraspinal Muscles during Isokinetic Exercise in Adolescents with Idiopathic Scoliosis with A Cobbs Angle Less than 50 Degrees Chang Gung Medical Journal 2010;33:540-50
The subject improved in most measures, especially with pain, combined thoracic and lumbar rotation and posture. Pain levels improved significantly, as did qualityof-life measures (SRS-22) and pulmonary function(UCSD SOB) (UCSD SOB): San Diego Shortness of Breath questionnaire (SRS-22) : The Scoliosis Research Society-22 questionnaire The subject completed three pre-tests and post-tests before and after completing 6 weeks of MFR treatment consisting of two sessions each week for 60 min. Conclusion: significant improvement of the self-reported questionnaires.
Aaron LeBauer, Robert Brtalik, Katherine Stowe. The effect of myofascial release (MFR) on an adult with idiopathic scoliosis. Journal of Bodywork and Movement Therapies (2008) 12, 356363