Non-Idiopathic Spine Deformities in Young Children

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The only subtypes of this condition are related to age. Early onset is recognized in children under 8 years old while late onset starts after the age of 8. Children who develop large curves at a young age may experience adverse lung development and growth that can lead to an early death due to breathing difficulties.

In congenital scoliosis patients have malformed bones that grow crookedly over time. Children are born with this condition and the cause is unknown. The management of these patients is very different from those with idiopathic scoliosis. Surgery is generally needed to correct or control these deformities. Children with neuromuscular scoliosis will have associated underlying abnormalities such as cerebral palsy muscular dystrophy or many other neurologic or genetic syndromes that may affect the scoliosis.

It is important when evaluating children to exclude other associated conditions by a careful medical and developmental history and physical examination. Idiopathic scoliosis affects approximately 2 to 3 percent of all children under the age of It is estimated that about 1 in 1 people will experience significant progression of their scoliosis. The frequency of small curves in girls and boys is equal.

For curves that are progressive however statistically girls out number boys 7 to 1. Idiopathic scoliosis can be diagnosed through a careful physical examination by a physician. This examination involves the patient bending forward while he or she is standing in front of the physician and leaning either toward or away from the physician.

A key sign of this condition is asymmetry of the ribs or surrounding muscles due to rotation of the spine. This presents as a bump along the spine and can be easily recognized when the child bends forward. X-rays of the spine can confirm whether or not scoliosis is present.

Medications No. Medication has not been shown to affect the progression of scoliosis. To date no exercise regimen or program has been shown to affect the likelihood of curve progression for scoliosis. Muscle strengthening or generalized conditioning may help mechanical back pain problems. However some patients particularly younger patients with curves that are not severe can be treated with a brace.

There is some controversy about this but there are some studies that have shown this to be effective when used in the appropriate patients. Non-operative intervention such as massage physical therapy chiropractic manipulations exercise programs and electric stimulation do not adversely affect the spine but have not been shown to stop or prevent the progression of scoliosis.

Incidence and Prevalence

Spinal fusion has been shown to be very effective in correcting the deformity and preventing further progression of scoliosis. Spinal fusion is generally recommended if other non-operative methods of controlling scoliosis have failed. The most common is to perform a spinal fusion where a surgical incision is made and the spine is exposed either from the back which is called a posterior approach or from the side which is called an anterior approach. Rods are fixated to the spine from the direction of the approach.

Over the last 10 to 15 years the use of anterior spinal procedures has increased. These procedures involve approaching the patient from the side and inserting the metal rods to support the spine. The rods are attached directly to the vertebral bodies. Telescopic instruments are inserted into the chest with the lung deflated and metal rods can be attached to the vertebra without needing to make large incisions. The technique is useful for moderately large curves in the chest but is technically demanding and is best done by medical centers with extensive experience in thoracoscopic work.

Q: Patients who have a curve in the chest area where the spine is tilted more than 50 degrees or are curved in the lower portion of the back where the spine is tilted more than 40 to 45 degrees should consult a spinal deformity specialist for information regarding surgical procedures such as spinal fusion.


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If a child is finished growing and the curve in the chest is 50 to 60 degrees or if the curved lower portion of the back is 40 to 45 degrees and the child is not experiencing symptoms or is not bothered by his or her back it is reasonable not to perform surgery on these patients. The worse case scenario for scoliosis is that the deformity will progress over time. If that occurs then delaying surgery is not recommended as the deformity can become quite severe and increasingly difficult to manage.

Also the risks of surgery will increase with an extremely large deformity. As outlined above conventional options include spinal fusion through either a posterior or anterior approach. In some cases a combination of an anterior and posterior approach will be necessary to effectively stabilize the back.

Adolescent idiopathic scoliosis and back pain

For very young children with scoliosis that is progressive and for whom bracing has not been successful stabilization of the back may be done by inserting metal rods to support the spine without performing a spinal fusion. A newer method involving stapling of the spine to try to modulate the growth is currently under review but it is not yet approved for general use. The success rate of stable fusion and correction of spinal deformity is very high in experienced hands. The average curve correction is approximately 70 percent and the likelihood of complications has been about 2 to 3 percent overall.

The fusion of the bones enabling the bones to grow together is permanent. There are concerns about long-term degenerative arthritis that may appear 30 to 50 years later in segments of the spine that were not fused. Currently there is not adequate follow-up information on the procedure to know the frequency of this problem. The urgency of spinal fusion is based on how rapidly the curve is changing.

For a child who is in the early stages of their pubertal growth spurt the spine can increase deformity at a rate of up to 2 to 3 degrees per month so while scoliosis surgery is plainly not an emergency neglecting rapidly progressive curves for long periods of time is not a good idea. As an adult or someone in the later stages of growth the rate of change will only be 1 to 2 degrees per year therefore the urgency is less. There is an increasingly recognized possibility that infection can occur for up to two to three years after the initial procedure.

In these cases repeat surgery will sometimes have to be performed to get the bone to effectively grow together. This concern may not be apparent for several years after the initial procedure. They may require additional surgery to clean out the infection long-term use of antibiotics until the bones are solidly healed and in some cases may require removal of the metal rods and implants to allow for final treatment of the infection. It is thought that a blood flow problem to the spinal cord may be created.

By relaxing the spine tension will be alleviated and this should help patients regain function. Children are advised to be in good general health and well nourished. In most healthy young people this will not be an issue.

Description

As long as the curve is not changing dramatically surgery can be postponed indefinitely. If a curve is stable and changing at a very slow rate the observation period can be quite long. In general surgery to treat a curve that is increased by 10 to 15 degrees is not more complicated or difficult. However if a curve increases by 30 to 40 degrees the magnitude of difficulty of surgery is greater and safety is less certain. Most commercial and government-sponsored insurance plans will cover this procedure. Many children in the state of Washington and nationally are covered by Medicaid which will also cover the cost of the surgery.

Spinal fusion is a complicated and technically demanding procedure. This procedure should be performed by a medical team whose members perform a high volume of these surgeries and at institutions where they are experienced in spinal cord monitoring and offer good anesthesia support. For younger children undergoing this procedure the team should include a pediatric anesthesiologist.

If an anterior spinal fusion is performed the surgeon should have experience with chest and abdominal procedures. If thoracoscopic procedures are to be performed there should be a team in place that has received formal training in these techniques and is experienced with thoracoscopy procedures. A good resource for spinal surgeons is the Scoliosis Research Society www.

This organization includes surgeons who perform high volumes of spine surgery and are skilled in spinal reconstruction for pediatric spine conditions. The site includes a listing of skilled orthopedic surgeons who have experience in pediatric conditions. Adult facilities may also have expertise provided they have a pediatric unit and a designated and skilled spine team.

For posterior procedures the spine is exposed after the patient is positioned face down on a special frame. The joints between the bones are removed and then the spine is straightened by attaching rods to the hooks or screws. The spine is then repositioned and the screws and hooks are tightened securely to the rod. Usually bone grafts serve as scaffolding for new bone cells to grow into. The bone graft can be taken from the patient or can be taken from the bone bank.

In children either bone supply works equally well for healing. It is advisable to discuss the options thoroughly with the surgeon and to evaluate the pros and cons of either bone graft source. The spinal cord is monitored throughout surgery to track impulses up and down the spinal cord.

This is a precaution taken to add an extra margin of safety and to decrease the possibility of cord injury. In the majority of cases in braces were not used. For anterior procedures the patient is placed on his or her side.

Infantile Idiopathic Scoliosis | Johns Hopkins Medicine

An incision is made to the spine either through the flank for the abdominal area or through the chest for the thoracic area. Screws are placed into the bone and the discs between the vertebrae are removed. Bone is then placed into these areas to help stimulate bone healing in between vertebrae.

A rod is attached to the screws and the spine is straightened and locked securely into position. Braces are often not used after surgery. After either anterior or posterior surgery a tube is typically left in to drain off any bleeding that occurs after the surgery. Monitoring of spinal cord function is done during scoliosis surgery. The standard monitoring should include monitoring of the pathways that transmit sensation and of the pathways that transmit motor movement.

Most patients are administered general intravenous IV anesthetic. A medication called Propofol is often used along with pain medication and Nitric Oxide which is a gas to help sedate the patient and help him or her drift off to sleep. The use of paralytic agents is often avoided due to the potential of interfering with the spinal cord monitoring. The length of surgery depends on how much of the spine needs to be fused and the approach that is used. Most anterior or posterior surgical procedures take three to five hours. For decades, scoliosis screenings were a routine part of school physical examinations in adolescents.

The U. Preventive Services Task Force and American Academy of Family Physicians recommend against routine scoliosis screening in asymptomatic adolescents, concluding that harm from screening outweighs the benefit because screenings expose many low-risk adolescents to unnecessary radiographs and referrals. In contrast, the Scoliosis Research Society, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, and Pediatric Orthopaedic Society of North America suggest that the potential benefit of detecting scoliosis early justifies screening programs, but greater care should be used in deciding which patients with positive screening results need further evaluation.

The goal for primary care physicians is to identify patients who are at risk of developing problems from scoliosis, without overtesting or overreferring patients who are unlikely to have further problems. Physical examination with the Adam's forward bend test and a scoliometer measurement can guide judicious use of radiologic testing for Cobb angle measurement and orthopedic referrals. Treatment options include observation, braces, and surgery. Males and females are about equally likely to have minor scoliosis of approximately 10 degrees, but females are five to 10 times more likely to progress to more severe disease, possibly needing treatment.

Preventive Services Task Force and the American Academy of Family Physicians recommend against routine scoliosis screening in asymptomatic adolescents. A scoliometer measurement of less than 5 degrees likely does not require follow-up. A scoliometer measurement of 10 degrees or greater requires radiologic evaluation for Cobb angle measurement. The exact pathophysiologic mechanism for scoliosis is unknown. A genetic factor has been implicated in the development and progression of scoliosis. Preventive Services Task Force USPSTF did not find good evidence that screening in asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than no screening.

It also found fair evidence that treating adolescent idiopathic scoliosis decreases pain and disability in only a small proportion of patients, and that treatment of adolescent idiopathic scoliosis detected through screening leads to moderate harms e. The accuracy of the most common screening test, the Adam's forward bend test, with or without a scoliometer, is variable.

The USPSTF found that most cases detected through screening do not progress to clinically significant scoliosis, and scoliosis requiring surgery is likely to be detected without screening. In a prospective study in the Netherlands that followed more than 30, students 10 to 14 years of age for up to three years, annual scoliosis screening in addition to the usual biennial health checkup detected no cases of idiopathic scoliosis requiring surgery, and the authors concluded that additional annual scoliosis screening was not needed.

The Scoliosis Research Society, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, and Pediatric Orthopaedic Society of North America convened a task force in supporting scoliosis screening, while also recognizing the need for greater care in deciding which patients with positive screening results need further evaluation.

They list prevention of deformity progression with brace treatment and earlier recognition of severe deformities requiring surgery as potential benefits of screening. The challenge for the primary care physician is differentiating adolescents with higher-risk scoliosis requiring referral or intervention from those with lower-risk scoliosis requiring observation and no intervention. The USPSTF suggests that most patients who need treatment will be detected without screening, 14 when presenting with visible curvature or possibly incidentally during another type of examination.

Physical examination for scoliosis mainly consists of the Adam's forward bend test Figure 1. Adam's forward bend test for scoliosis screening. The patient stands and bends forward at the waist. The examiner assesses for back symmetry from behind and beside the patient. Any back or rib cage abnormalities, such as a rib hump arrows , may be a sign of scoliosis. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician. The examiner may then attempt to quantify the spinal curve and rotation with a scoliometer, or inclinometer 4 , 5 Figure 2.

The inclination angle measured by a scoliometer will help determine which patients may need radiography.

ETIOLOGY AND NATURAL HISTORY

The estimated magnitude of the spinal curve can be used to determine the angle of trunk rotation. The inclination angle measured by scoliometer will help determine which patients may need radiography. Cobb angle. Tangential lines are drawn from the superior end plate of the superior vertebra and the inferior end plate of the inferior vertebra. The angle formed at the intersection of these two lines is the Cobb angle 62 degrees in this image. A Cobb angle of at least 10 degrees is necessary for diagnosing scoliosis.

Although scoliosis is usually benign and rarely requires treatment, there are several characteristics that suggest more serious problems and a diagnosis of nonidiopathic scoliosis. Scoliosis rarely causes significant pain; therefore, severe pain should prompt evaluation for other possible etiologies.

Three major factors that determine whether scoliosis will progress are patient sex, magnitude of curve on presentation, and growth potential. The initial Cobb angle magnitude was the most important predictor of long-term curve progression and behavior past skeletal maturity, whereas initial age, sex, age of menarche, and pubertal status were less important prognostic factors. The authors suggested an initial Cobb angle of 25 degrees as an important threshold magnitude for long-term curve progression. The examiner may estimate growth potential based on age and Tanner stage; however, for more precise determination of growth potential, radiographs may be needed to measure the Risser grade.

The Risser grade measures bony fusion of the iliac apophysis Figure 4 21 , with higher Risser grades indicating greater skeletal ossification, hence less potential for growth and curve progression. Progression of scoliosis curve averages 0. The Risser grade is used to measure ossification of the iliac apophysis. Reprinted with permission from Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. The Tanner-Whitehouse 3 assessments, which assess skeletal maturity based on radiographic evaluation of the epiphyses of the distal radius, distal ulna, and small hand bones, were simplified and used to create a skeletal scoring system to estimate scoliosis behavior.

Table 1 shows predictions of scoliosis progressing to a degree curve, with its potential for surgical treatment, based on digital skeletal age staging and curvature at the time of the measurement.

Pediatric Scoliosis Symptoms & Screenings

Many patients could be stage 5 on the simplified Tanner-Whitehouse 3 scale, but be a Risser grade 0. Therefore, the prediction of scoliosis activity may be stronger with the simplified Tanner-Whitehouse 3 scale than with the Risser grade. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am. This information can help guide decisions about referral and treatment. Shaded cells correspond with combinations for which surgery would not be a plausible treatment. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence.

Determining which patients need referral to an orthopedist can be complicated, and clear indications are not always available. However, the trend in recent years is that fewer patients need radiography, and fewer patients who undergo radiography need treatment. A year follow-up study of late-onset idiopathic scoliosis including untreated patients and 62 age- and sex-matched volunteers found that patients with untreated scoliosis are productive, are high-functioning, and usually have little physical impairment other than back pain and cosmetic concerns. Data Sources : A PubMed search was performed using the key terms scoliosis, adolescent scoliosis, and scoliosis screening.

The search included randomized controlled trials, reviews, clinical trials, and meta-analyses. Search dates: October 16 and 18, ; September 1, Already a member or subscriber? Log in. Address correspondence to John P. Reprints are not available from the authors. Lonstein JE. Adolescent idiopathic scoliosis. Scoliosis: a straightforward approach to diagnosis and management. Roach JW. Orthop Clin North Am. Bunnell WP. Selective screening for scoliosis. Clin Orthop Relat Res. Scoliosis and kyphosis. Philadelphia, Pa. O'Connor F. Pediatric Orthopedics for the Family Physician.

Weiss HR.