Spinal Deformities

Scoliosis

• Definition: Lateral curvature of the spine >10° accompanied by vertebral rotation
• Types:
  • Postural: Secondary to pathology outside the spine (e.g., limb length discrepancy, pelvic tilt)
    • Correctable/Disappears with sitting
  • Structural: Fixed deformity that does not disappear with sitting
    • Congenital bony abnormality
    • Idiopathic (most common)

Adolescent Idiopathic Scoliosis (AIS)

Most common type of scoliosis

Clinical Presentation

• Demographics: Adolescent girls (10-16y) more common than boys (12-16y)
• Presenting complaint: Back deformity or shoulder inequality
• Key feature: Painless (pain suggests tumor or infection)
• Progression: Curves progress continuously until maturity, then slower after maturity
• Complications: Severe curves may affect pulmonary function

Clinical Findings

• Leaning of entire body to one side
• Head not centered directly above the pelvis
• Shoulders at different heights
• One shoulder blade more prominent than the other
• Rib cages at different heights (due to vertebral rotation)
• Uneven waist
• Raised, prominent hip
• Curve increases on forward flexion
  • Compensatory scoliosis disappears on flexion

Diagnostic Measurements

Cobb’s Angle

• Measures the amount of curve
• Angle between perpendicular lines to the uppermost and lowermost vertebral bodies in the curve

Risser’s Sign

• Measures potential for growth progression
• Ranges from 0 (no ossification) to 5 (complete bony fusion)
• Lower grade = Higher progression potential

Progression Determinants

1. Patient gender: Female > Male (3:1 ratio)
2. Curve magnitude: Higher curves progress more
3. Future growth potential: More growth = more/quicker progression
   • More growth potential = more and quicker progression
   • Less growth potential = less and slower progression
   • This is assessed using: Risser’s sign

Scoliosis Treatment Guidelines

Goal: Prevent curve progression

Monitoring:

• Follow-up every 6 months
• Exclude other causes (tumor, infection)

by photography, clinical evaluation and radiological measuring the curve every 4m necessary before deciding conservative or surgical treatment

Treatment Options:

Curve Severity	Treatment Approach
<10°	No treatment needed
20°-40°	Bracing (23/24 hours)
>40° (in skeletally immature)	Surgical intervention

Bracing 20°-40°

• Worn 23/24 hours daily
• Compliance is crucial
• Reduces rate of progression
• Conservative approach with stretching exercises

Surgical Treatment

Indications:

• Curves >40° in skeletally immature patients
• Progressive curves

Procedure:

• Correction
• Instrumentation
• Fusion

Kyphosis

Less common than scoliosis

• Kyphosis: Abnormal thoracic curve >40°
• Kyphos: Sudden angular deformity (e.g., congenital/TB)

Types of Kyphosis

• Mobile: Associated with ligament laxity
• Fixed:
  • Ankylosing spondylitis
  • Scheuermann’s disease (Adolescent kyphosis)
  • Senile osteoporosis (Elderly patients)

Senile Osteoporosis

• Pathology: Anterior wedge compression of several vertebrae
• Result: Rounded back in elderly people
• To be discussed in “Metabolic Bone Disorders”

Scheuermann’s Disease

Pathology:

• Irregular ossification of vertebral body epiphysis
• Central herniation of disc material into the body (Schmorl’s Node)
• Wedging of vertebrae

Clinical Features:

• Developmental condition affecting teenagers
• Boys > Girls
• Gradually increasing rounded fixed kyphosis

Radiographic Findings:

• Irregular ossification of vertebral body epiphysis
• Schmorl’s nodes -Central herniation of disc material into the body
• Wedging of vertebrae

Treatment:

• Mild: Reassurance
• Mild early: Bracing
• Severe: Surgery (correction & fusion)

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COMBINE W/ ABOVE

Spinal Deformity

Definitions

• SCOLIOSIS: Lateral curvature of the spine >10° accompanied by vertebral rotation
• KYPHOSIS: Dorsal curvature of the spine >40°

Scoliosis

Types

Compensatory Scoliosis

• Secondary to pathology outside the spine
• Examples: Limb length discrepancy, pelvic tilt
• Disappears with sitting

Structural Scoliosis

• Fixed deformity that does not disappear with sitting
• Usually associated with bony abnormality

Structural Scoliosis Categories

• Idiopathic:
  • Infantile
  • Adolescent
• Neuropathic (paralytic)
• Myopathy
• Neurofibromatosis

Adolescent Idiopathic Scoliosis (AIS)

Natural History

• Present in 2-4% of children aged 10-16 years
• Gender ratio: Equal for small curves (≤10°), but 10:1 female:male for curves >30°
• Progression: More common in girls (higher treatment requirement)

Clinical Features

• Shoulders at different heights – one shoulder blade more prominent
• Head not centered directly above the pelvis
• Raised, prominent hip
• Rib cages at different heights
• Uneven waist
• Skin texture changes overlying the spine
• Leaning of entire body to one side

Progression Factors

• Back pain not significantly higher in patients with scoliosis
• Curves <30° at bony maturity unlikely to progress
• Curves >50° at maturity progress 1° per year
• Life-threatening pulmonary effects occur only when curve >100°

Key Determinants of Progression

1. Patient gender
2. Future growth potential
3. Curve magnitude at diagnosis

Growth Assessment: Risser Grading

• Measures bony fusion of iliac apophysis
• Range: 0 (no ossification) to 5 (complete bony fusion)
• Lower grade = higher progression potential

Imaging

• X-ray:
  • AP and LAT of entire spine (Cobb angle measurement)
  • AP pelvis (Risser grade)

Cobb Angle Measurement

• Select most tilted vertebrae above and below curve apex
• Angle between intersecting lines drawn perpendicular to superior vertebra top and inferior vertebra bottom

Treatment Guidelines

Treatment Goals

• Prevent curve progression
• Periodic evaluation through photography, clinical assessment, and radiological measurement

Treatment Indications

• No treatment for curves <10°
• Treatment initiated if:
  • Skeletally immature curves <19° progress 10°/year
  • Curves 20-29° progress 5°/year

Bracing

Indications:

• Curves between 20-40°
• Well-balanced double curves
• Young children awaiting surgery
• Prevention of recurrence

Surgery

Indications:

• Curves >40° in skeletally immature patients
• Adult documented progressive curves

Procedure:

• Correction
• Instrumentation
• Fusion

Kyphosis

Definition

Backward angulation above 40 degrees

Types

• Mobile:
  • Compensatory
  • Postural
• Structural:
  • Angular (e.g., congenital, TB)
• Rounded:
  • Scheuermann’s disease
  • Senile osteoporosis
  • Ankylosing spondylitis

Scheuermann’s Disease

Pathology

• Irregular ossification of vertebral body epiphysis
• Central herniation of disc material into the body (Schmorl’s Node)
• Wedging of vertebrae

Types

• Thoracic
• Thoracolumbar

Clinical Features

• Onset: Shortly after puberty (teenagers)
• Gender: Boys > girls
• Location: Mid-thoracic
• Presentation: Rounded shoulders, fixed rounded kyphosis

X-ray Findings

• Irregular ossification of vertebral body epiphysis
• Schmorl’s nodes (central disc herniation)
• Vertebral wedging

Treatment

• Mild cases: Often unnoticed
• Early mild cases: Bracing
• Severe cases: Surgical intervention

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