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1. Scoliosis
Dr Nor Hidayah Zainool Abidin
International Islamic University of
Malaysia (UIAM)

2. OUTLINES
Normal vertebral curvature
Definition
Types
• Non structural/ Structural
Clinical features
Imaging
Treatment
• Conservative/ Operative
Summary

3. Normal Spine
• Primary curves are the natural
curves in the spine that we are born
with
– thoracic and pelvic curves.
• Compensatory curves/ secondary
curves, develop after birth in
response to learned motor skills
– Cervical section  infant learning to
hold his or her head upright and
learning to sit unsupported
– at 3 to 4 months of age lumbar
lordosis
– lumbar sectionsbegins to develop
as a child learns to walk

4. Scoliosis
• Abnormal, side-to-side curvature of
the spine
– Deviation from normal vertical line
– At least 10 angulation
• Vertebral rotation Pedicle position

5. History
Family history
Recent growth history
Sexual maturity
•Menses
Pain
•Fatigue pain’
• Post diagnostic pain
• ‘Severe pain’

6. Clinical features
• Obvious skewed back
• Rib hump in thoracic curve
• Asymetry prominence of 1
hip (thoracolumbar curves)
• Skin pigmentation
• Look for congenital
abnormalities
• Scapula level
• Breast and shoulder level
• Lower limbs length
• Cardiopulmonary function

7. • Adam’s test (bend forward)
• Scoliometer : measures angle of trunk rotation
(ATR)
98% of curves > 20 have ATR of at
least 5
•Fairly high false positive
•High sensitivity, low specificity

8. Cobb’s angle
• Maximal angle from the superior endplate
of the superior-end vertebra to the inferior
endplate of the inferior inferior-end
vertebra.
• Major factor in the clinical decision-making
process.

9. Curve Progression
• Will not progress after skeletal
<30 maturity
• Progress 10 -15 in lifetime
30 -50
• Progress about 1 per year
>50
• Affect cardiopulmonary
>90 function

10. Risser’s sign
• Iliac apophyses
– Ossification from lateral to medial
– Starts ossify shortly after puberty
• Skeletal maturity  curve progresses
the most during period of rapid
skeletal growth
• When fusion complete (spinal
maturity has been reached) 
coincides with fusion of vertebral ring
apophyses
• Further increase in curvature is
neglegable (stage 5)

11. Postural scoliosis
• Deformity is secondary or compensatory to
some condition outside the spine
(nonstructural/compensatory)
– Short leg
– Pelvic tilt (due to contracture of the hip)
– Local muscle spasm associated with PID (sciatic
scoliosis)
• sit/ bend forward  usually
• Usually temporary and disappears  treat
underlying cause

12. Infantile (0-3
years old)
Idiopathic Juvenile (4-9
scoliosis years old)
Neuropathic and Adolescent (10
myopathic years to
scoliosis maturity)
Congenital
scoliosis

13. Congenital scoliosis
• present at birth
• usually is due to a deformity in 1 or more
vertebrae.
• Associated with other congenital anomalies
• Overlying tissues  angiomas,naevi, excess
hari, dimples, fatpad or spina bifida
• Clinical examinations and imaging to
– Discover other congenital anomaly
– To assess the risk of spinal cord damage (e.g:
cord tethering which must be dealt prior to
curve correction)

14. Congenital Scoliosis
Defects of • Block vertebra
segmentation • Unilateral bar
Defects of • Hemivertebra
Formation • Wedge vertebra

15. Neuropathic and myopathic scoliosis
Diseases: Deformity of the spine  often severe
• cystic fibrosis in patients with neuromuscular
• various types of scoliosis
muscular dystrophy
• spina bifida The greatest problem loss of
• cerebral palsy stability and balance sitting difficult
• Marfan syndrome
• rheumatic disease
X-ray with traction applied shows
• myelomeningocele extend to which the deformity is
• tumors correctable

16. Idiopathic scoliosis
• 80% of all scoliosis
• > 10 curve
• No identifiable cause
• Three different groups
– Infantile (0-3 years old)
– Juvenile (4-9 years old)
– Adolescent (10 years to maturity)
• Simpler division
– Early onset (before puberty)
– Late onset (after puberty)

17. Idiopathic scoliosis
Infantile Idiopathic Juvenile Idiopathic Late onset (Adolescent)
Scoliosis Scoliosis • Primary thoracis curves are
• Males • 12-21% of idiopathic usually convex to the right
• Most curves spontaneously scoliosis • Lumbar curve to the left
resolve • 3-6 years: male = female • Intermediate
• Surgical intervention can • 6-10 years: female:male 10:1 (thoracolumbar) and
result in: Significantly • Curve progression is combine (double primary)
shortened trunk common can also occur
• 70% require some form of • Curve < 20 either resolve
treatment spontaneously or remain
unchanged

18. Predictor for progressions
• Very young age
• Marked curvature
• An incomplete Risser’s sign at presentation
• In pre-purbertal, rapid progression is liable at
growth spurt

19. Warning Signs Prompting Extensive
Evaluation
• Convex left thoracic curve
• Severe, large curves in very young children
• Scoliosis in boys
• Painful Scoliosis
• Sudden rapid curve progression in a previously stable
curve
• Extensive curve progression after skeletal maturity is
• reached
• Abnormal neurological findings
• Small, hairy patch on the lower back

20. Treat or Not to Treat?
Observation
Bracing
Surgical
intervention
Prevent mild deformity from becoming
severe. To correct an existing deformity
that is unacceptable to the patient

21. Non-operative treatment
Bracing  treatment of progressive scoliotic
curve 20 -30
• Wear 23 hours and does not preludes full daily
activities including sports and exercis

22. Milwaukee brace
• Thoracic support -- pelvic
corset connected to
adjustable steel supports to
cervical ring carrying occipital
and chin pad
• Purpose to reduce lumbar
lordosis and encourage active
stretching and straightening
of the thoracic spine

23. Boston Braces
•Sug fitting underarm brace
that provided lumbar or low
thoracollumbar support

24. Problems with Braces
• Argued efficacy
• Most orthopaedics surgeon waits until the curve progress to the
stage when corrective surgery is justified
• Narrow treatment window to initiate
– Bracing will not improve the curve  stop it from
getting worse
– Bracing has not proven to be effective for older
adolescents
• Poor compliance
• Must have good orthotist
– Proper education (How and when)

25. Surgical Indications
• Curve > 30 that cosmetically unacceptable especially
in pre-pubertal children who are liable to develop
marked progression during growth spurt
• Milder deformity that is deteriorating rapidly
• To halt progression of the deformity
• To straightened the curve (including
Objectives rotational component)
• To arthrodese the entire primary
curve by bone grafting

26. Surgical treatment
• Anterior fusion (ASF)
– Single rod
– Double rod
• Posterior fusion (PSF)
– Hooks
– Hooks and pedicle screws
– All pedicle screws.
• ASF/PSF

27. Complications of surgery
• Neurological compromise
• Spinal decompensation
• Pseudoarthrosis
• Implant failure

28. References
• Apley’s Orthopaedics Textbooks, 2010
• Scoliosis: Review of diagnosis and treatment, J.A
Janicki, and B. Alman, Paediatr Child Health. 2007
November; 12(9): 771–776.
• Spinal Curves and Scoliosis, S. Anderson,
September/October 2007, Vol. 79/No. 1
RADIOLOGIC TECHNOLOGY
• Patterns of presentation of congenital scoliosis, S
Mohanty & N Kumar, Journal of Orthopaedic
Surgery 2000, 8(2): 33–37.