Idiopathic Scoliosis
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Each specific situation has to be evaluated on an individual basis. EuroSpine and its members cannot be held responsible for any misunderstandings (or misdiagnosis) based on the information provided here, which in no way attempts to replace a targeted evaluation.
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The vertebral column is straight when seen from the front or back (frontal plane). When viewed in profile (sagittal plane), the normal column is seen to have four curves, two with posterior convexity (concave forward), termed kyphosis, and two with anterior convexity (convex forward), termed lordosis. The cervical and lumbar regions are in lordosis and the thoracic and sacral regions in kyphosis. Commonly we refer to cervical lordosis, thoracic kyphosis and lumbar lordosis.
SCOLIOSIS is an alteration of the normal morphology of the spinal column.
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Secondary scoliosis is usually associated with neuromuscular (cerebral palsy, poliomyelitis, myelomeningocele, myopathy, etc.) or connective tissue diseases (Marfan syndrome, Ehler-Danlos syndrome, etc.). When scoliosis is secondary to a vertebral malformation it is known as congenital scoliosis.
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1. The growth potential of the patient
2. The magnitude of the curve
3. The type of curve
4. The sex of the patient
Growth potential can be assessed on the basis of the patient’s age, skeletal maturity and the appearance of secondary sex characteristics or menarche (first menstruation). Younger patients with a less mature skeleton and an absence of secondary sex characteristics and menstruation have a higher potential for growth and a greater risk of scoliosis progression. By contrast, the lower the growth potential, the smaller the risk of progression.
Skeletal maturity is usually assessed by determining the ossification of the iliac crest, which is divided into five stages. The appearance of secondary sex characteristics has also been classified into five stages according to breast and genital development and the distribution of pubic hair.
The risk of progression is higher in scoliosis involving double curves than single curves. Lumbar scoliosis carries a lower risk of progression than thoracic scoliosis.
The factors that best define the risk of progression in scoliosis are the growth potential and the magnitude of the curve. The theoretical risk of progression has been established on the basis of these two factors.
Table Peterson, Nachemson JBJS 1995; 77A:823-7
Nevertheless, it should be emphasized that it is impossible to predict with complete accuracy which curves will progress and which will not.
* In the adult (in adults): Once growth has stopped, the risk of progression is minimal or null in patients with thoracic scoliosis less than 50º or lumbar/thoracolumbar scoliosis less than 30º. Adult idiopathic scoliosis with curves greater than 50º may progress slowly at a rate of 0.5–1º/year.
* Progression of scoliosis can involve an aesthetic problem and lead to functional problems. Respiratory disorders may develop in large curves greater than 80º. Nonetheless, the mortality rates and vital prognosis in individuals with scoliosis are comparable to those of the general population.
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Characteristics of the physical examination
Individuals with scoliosis often display some type of trunk asymmetry. One shoulder may appear to be higher than the other, there may be a tilt at the waistline, or one scapula may be more prominent. Probably the most effective way to detect scoliosis is to have the patient bend forward with the knees straight and flexing the waist (forward-bending test). It is quite easy to detect trunk asymmetries by viewing the patient from behind while he/she is in this posture, and scoliosis should be suspected when asymmetry is evident.
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Exercise and physiotherapy do not reduce the magnitude of the curve or the risk of progression, but these options can be used as coadjuvant therapy to improve posture and strengthen the muscles.
Orthotic treatment (corset/brace) modifies the natural history of adolescent idiopathic scoliosis, reducing the risk of progression. However, as long-term studies have demonstrated, the initial correction achieved with bracing may be lost over time. Braces are most effective in curves of less than 40º and are one of the treatments of choice for growing patients with curves of 20–40º. Only a small number of patients with curves of less than 20º progress.
Bracing does not impede the progression of scoliosis in patients who have stopped growing.
Specialist's opinion:
No treatment | |
Observation and control | |
Brace | |
Surgery |
No treatment | |
Observation and control | |
Brace | |
Surgery |
Surgical treatment is usually proposed for curves of more than 60º, or 40–60º in growing patients with documented progression despite bracing. Curves of more than 40º that the patient considers an unacceptable deformity may also undergo surgery.
Specialist's opinion:
No treatment | |
Observation and control | |
Brace | |
Surgery |
No treatment | |
Observation and control | |
Brace | |
Surgery |
No treatment | |
Observation and control | |
Brace | |
Surgery |
Specialist's opinion:
No treatment | |
Observation and control | |
Brace | |
Surgery |
EuroSpine, April 2007