00:00
When we classify
scoliosis,
we classify it based on a couple
of different criteria.
00:07
What is the
reversibility?
Does it go away with
motion and activity?
What is the
severity?
Is it 10 to 20 degrees,
20 to 30?
Is it greater than 30 or
greater than 50
because it's a different natural
history for each of those?
Is there an identifiable
cause?
Is there a muscle weakness or
muscular dystrophy?
Is osteogenesis
imperfecta?
Does a student have blue
sclera, weakness,
Is osteogenesis
imperfecta?
Does a student have blue
sclera, weakness,
café au lait spots that might be
indicative of a neurofibromatosis?
All of those things are clues that
the person has a scoliosis.
00:40
We also look at the area
of the curvature,
as all being very
important.
00:47
So if a curve is
structural,
it does not go away
with movement.
00:52
If it is
functional,
then the curve will go away
with particular motions.
00:57
That is when you have a student
or a person forward bend.
01:01
If you see it going away,
you can call it functional.
01:04
Do you have scoliosis changing
from functional to structural?
Yes, you can, particularly with an
unequal limb length.
01:14
If you have changes
in body structure,
seeing if there is an amputation
or loss of a limb.
01:20
If there is trauma or disk deterioration
or degeneration,
you can see the change of a functional
to a structural scoliosis.
01:29
Fibrosis of the ligaments and fascia
can lead to a change
and if the person doesn't have
full activity or has limited action.
01:37
Those are things that
can lead to a change
from a reversible scoliosis
to a permanent scoliosis.
01:44
When we classify it in the
school-based screening,
they either have
no scoliosis,
they have a mild scoliosis
of 10 to 15 degrees
which we questioned, follow,
and want to monitor.
01:56
They may have a
moderate scoliosis
which is a real noted 10 to
45 degree curvature,
at which case the student is going
to need a Cobb radiograph
or a posterior-anterior
radiograph.
02:10
You take an X-ray from behind
towards the front
and we'll go over how you
measure it after that.
02:15
Or is the scoliosis greater
than 50 degrees,
a real, apparent curvature
of the spine
that's going to have real
and serious lasting effects.
02:24
If you have a curvature greater
than 50 degrees,
we start looking at how
it's affecting the heart
and how it's affecting
the lungs.
02:31
Those are important complications
of a severe scoliosis.
02:36
Most times when a person
has a scoliosis,
we don't know
the cause.
02:40
We don't find
the cause.
02:41
It's something that's just uncovered
on a screening exam.
02:46
70 to 90 percent of scoliotic
curves are idiopathic.
02:50
We don't know
the cause.
02:52
As we learn more
about scoliosis,
we start looking at relatives with
scoliosis and other complications
including sacral base
unleveling
or other changes that
affect biomechanics.
03:05
So idiopathic is also
called infantile,
juvenile or adolescent, AIS, adolescent
idiopathic scoliosis.
03:14
You can have a
congenital scoliosis,
an acquired scoliosis, or a
neuromuscular scoliosis as well.
03:22
Those are the four different
classifications of a scoliosis.
03:25
We do have some general
other patterns that we see
that are somewhat nebulous
and where we classify them.
03:33
In infantile idiopathic
scoliosis,
it's usually due to
gravitational causes,
mechanical causes, and
the immaturity of the spine.
03:44
We have some bending that
is institutionalized
or caught in the skeletal system
but can go away.
03:52
The ideal treatment with an infantile
idiopathic scoliosis is trying to prevent it.
03:57
One of the problems is we see
more scoliosis in children
when they're put to bed
on their back
which is the new recommendation for
the American Academy of Pediatrics.
04:08
The idea is to prevent sudden
infant death syndrome
or sleeping
sickness of kids.
04:15
Putting them on their
back is safer.
04:19
But the parallel to that is
there is a slight increase
in the amount of scoliosis when children
are put to sleep on their back.
04:28
We do treat the
curvatures
and try and get rid of them
as quickly as possible
usually with an orthotic and
sometimes with the brace.
04:35
The earlier this is done, the better
outcome we feel there will be.
04:39
The evidence on this is
still being developed.
04:41
We don't have clear, good,
definitive answers yet.
04:44
An important reason to
diagnose scoliosis early
is that when the scoliosis starts can
determine what kind of side effects
or complications
you have.
04:54
If a scoliosis develops
before five years of age,
it's important to monitor for
cardiac or respiratory issues.
05:01
We do know that bony growth
is affected by a scoliosis
and that you can have a
change in the diameter
and the size and the shape
of the thoracic cavity.
05:10
So the growth of the lungs
will be affected.
05:13
Normally there's a tenfold
increase in the alveoli
from infancy to four
years of age.
05:18
This growth in alveoli and lung tissue
continues up to eight years of age.
05:23
So scoliosis this
early in life
can have a definite effect on the lung
tissue and lung functioning.
05:32
Juvenile idiopathic scoliosis
is when we diagnose it
between 4 and
10 years of age.
05:38
This is also a progressive scoliosis much like
the infantile idiopathic scoliosis.
05:44
If it's less than
20 degrees,
we tend to observe it with
an X-ray, a PA,
then every 4 to 6 months to see how quick
and how severe the progression is.
05:56
It varies
widely.
05:58
Some children will not have
much progression.
06:01
Once they have that
curvature
or the blocking of the vertebrae,
it tends to stick.
06:07
Others have a gentle
twisting and turning
that continues over
the next few years.
06:13
So it's important to be able
to predict what happens.
06:15
That's something you
do by monitoring
the curvature of the spine
on a regular basis.
06:21
If there continues
to be progression,
then you will consider bracing and
stabilization of the spine
by external means of which
bracing is the most common
and most frequently used.
While the bracing
generally has success when
it's done all day long
and people don’t get
out of the brace,
it is the most widely-used
non-operative treatment.
06:47
We try not to do surgery
at a young age
because it does expose
the child to other issues.
06:53
It's also not a
terminal treatment.
06:55
It's not the end
treatment.
06:57
They would require further
surgeries later on in life.
07:00
In order to limit the number of
surgeries, we do try and delay it.
07:04
One of the reasons we need to monitor
juvenile idiopathic scoliosis
is checking the top vertebrae
for crankshaft phenomenon,
looking at the anterior and posterior
aspects of the vertebrae
and seeing if fusion occurs.
We want to avoid
fusion of the vertebrae
to allow motion.
07:22
The other thing to
be aware of is
when people do get surgery,
generally rodding is done
to increase the straightness and
prevent further deterioration.
07:34
That's called Harrington
rods
and that's an attempt to
straighten out the spine.
07:41
Adolescent idiopathic scoliosis
is thought to be hereditary
in that it's seen in families and multiple
members of the family.
07:49
It has an association with a hypokyphosis,
less of a forward bending hump.
07:56
There are also possible CNS defects
that can be seen with this as well.
08:01
There may be a genetic contribution
as it is seen throughout families,
skipping generations and sometimes
skipping parts of the family altogether.
08:09
So it is something that is being
watched and studied.
08:12
Patients with AIS will often have a sibling or
a parent with scoliosis though.
08:17
We do not have the inheritance pattern
of the genetic loci worked out.
08:20
But it has been mapped to
chromosome 17 and 19.
08:24
With adolescent idiopathic
scoliosis,
you will have greater progression
in girls with boys.
08:30
It will start before
menstruation.
08:34
You will have a low
Risser sign.
08:36
We'll talk about a Risser sign and its
relation to growth in just a minute.
08:40
You will most likely have double curves
with the scoliosis starting in one area
and being compensated
for in another area.
08:48
It will be most likely starting
in the thoracic spine.
08:51
The curves do get severe.
It is important to measure
the height of the person because they have
the potential to lose height.
09:01
Congenital scoliosis is the second most common
type of scoliosis after idiopathic.
09:06
These are generally
progressive.
09:08
About three-quarters of congenital scoliosis
will continue to worsen throughout life.
09:12
It can be associated with
other congenital defects
like cardiac defects or
genitourinary defects.
09:19
In a congenital
scoliosis,
there is a specific
vertebral defect.
09:25
Oftentimes, there's a
failure to merge.
09:28
There's a failure of complete
formation of the vertebrae.
09:31
You'll see hemivertebrae, wedge vertebrae,
and segmentation,
where you may have an open aspect of the
vertebrae or incomplete formation.
09:41
So you have a failure of
complete segmentation.
09:43
It's often
unilateral.
09:46
It can be a bilateral
failure as well
or you can have a just open
area in the back of the vertebrae.
09:53
It's also not uncommon
to see fused ribs
in a patient with a
congenital scoliosis.
09:59
Another type of scoliosis
is acquired scoliosis.
10:02
This is a person who
has osteomalacia
or had severe low back pain
or had a psoas syndrome,
could have had a broken
leg or other fractures,
they may have a
hip prosthesis.
10:14
As a result of these
abnormalities,
you're going to have abnormal bone
formation in other places.
10:22
Acquired scoliosis is something
to pay attention to.
10:25
It happens and
you will see it.
10:29
The most common causes of
neuromusculoskeletal scoliosis
are going to be a leg
length discrepancy,
neurofibromatosis, or
quadriplegia.
10:37
When we look at neuromuscular scoliosis,
there could be a neuropathy
or it could be
mesenchymal.
10:43
If you want to look at the most
common causes of these,
for neuropathy it's going to
be cerebral palsy,
Friedreich ataxia, myelomeningocele,
spinal cord injury
or others that are listed here.
Of mesenchymal origin
are the congenital defects
like Ehlers–Danlos,
homocystinuria and
Marfan syndrome.
11:02
We can also talk about trauma
related neuromuscular scoliosis
which could be the direct
vertebral trauma,
extravertebral trauma. It could
be a severe trunk burn
or something that causes a thoracic injury
and a loss of use of the body.
11:18
Irradiation is another
possible traumatic cause.
11:21
In terms of tumor etiology of
a neuromuscular scoliosis,
you can have extramedullary
effects like in a neurofibroma
or intramedullary systems
like an astrocytoma.
11:34
You could have an
osteoid osteoma.
11:36
While rare,
the osteoblastomas
and bony tumors are a
real cause of a scoliosis.
11:43
There are also
myopathic causes.
11:45
You'll see that in arthrogryposis
and other conditions listed here
like Duchenne's muscular
dystrophy,
dysautonomia and the
hyperphosphatemia issues, hypervitaminosis A.
11:56
So here's the list of
the myopathic
related neuromusculoskeletal
issues causing scoliosis.
12:03
Then there are
miscellaneous causes.
12:05
It is very common to see
Charcot–Marie–Tooth causing a scoliosis
as well as osteogenesis imperfecta,
the blue sclera disease,
and the soft
bone disease.
12:17
Poliomyelitis which
we no longer see
or rickets are also possible
causes of scoliosis.
12:23
So the list is
noted here.
12:26
We will classify the scoliosis
based on location.
12:29
Again, scoliosis will often
have a double curvature.
12:34
We name it from the top of the curvature
and the first vertebrae.
12:38
We name it based
on the convexity.
12:43
Most frequent type of scoliosis is
going to be thoracic and lumbar.
12:47
There'll be balanced curves with the thoracic and
lumbar going in opposite directions.
12:52
You will have a crossover region
which is a dangerous region
because that's where you can have deterioration
and degeneration of the vertebrae.
13:01
You can have a single
thoracic scoliosis.
13:04
The progression in
this kind of scoliosis
can be damaging to the
heart and lungs as well.
13:12
A single lumbar scoliosis
also occurs.
13:15
That's associated with severe arthritic
changes and lots of pain as well.
13:21
A junctional thoracolumbar scoliosis is
also one that can occur.
13:24
You'll have a longer
curve with that.
13:27
It over stresses the spine and
causes arthritic changes
in area of greatest pressure
on the spine as well.