scoliosis clinical examination

1. Adolescent idiopathic scoliosis
From A to Z
By AO foundation
Patients examination

2. 1. General considerations
• Age
Usually older age is associated with a lower chance of curve
progression while patients presenting with the same degree of
curve at a younger age has a higher chance of curve progression
that may reach surgical indications.
• Curve magnitude at presentation
Curves less than 20° at presentation can usually be followed while
those presenting between 20° and 30° will usually undergo a trial
of brace treatment. If a patient presents with a curve magnitude
greater than 40° the chances of needing surgery eventually is high.
• Length of time post menarche
Length of time post menarche is an indication of skeletal maturity.
A person grows fastest one year before onset of menarche and
usually finishes growing two years after its onset.
• Presence of positive patient family history
AIS is an inherited condition with familial associations. A careful
family history should always be taken.

3. 2. Physical examination
• Assessment of
shoulder balance
Shoulder balance can
be assessed looking
at the patient
posteriorly as well as
anteriorly. If one
shoulder is higher
than the other it
should be noted.

4. 2. Physical examination
• Assessment of waist
crease/pelvic obliquity
Presence of
asymmetry of waist
crease, truncal shift
and pelvic obliquity
should also be
assessed by direct
visualization.

5. 2. Physical examination
• Assessment of angle
of trunk rotation
A scoliometer is used
to assess angle of
trunk rotation for the
thoracic as well as the
lumbar prominence
while the patient is a
forward bending
position.

6. 2. Physical examination
• Presence of any
cutaneous
abnormalities
The presence of
cutaneous
abnormalities such as
hairy spots or "café au
lait" spots can be a
presence of non-
idiopathic types of
scoliosis and should be
kept in mind.

7. 2. Physical examination
• Indicators of maturity
Development of secondary sexual
characteristics is a rough indication of
skeletal maturity and should be kept in mind.
• Gait
Gait assessment is important for indicating
any possible leg length discrepancies or
possible ataxia which may be an indication of
spinal cord disorders.

8. 2. Physical examination
• Sensory and motor
examination
Sensory and motor
examination is
performed in routine
fashion to ensure
there are no deficits
or asymmetries.

9. Reflex examination
• Reflex examination
Upper and lower extremities
should be examined for
asymmetries and deep
tendon reflexes. In addition
the abdominal reflex should
be assessed for
asymmetries as well. The
presence of reflex
asymmetry from side to side
can be an indication of
neuro axis abnormalities
and may warrant further
examination such as the
use of MRI.

10. • Clonus or a positive
Babinski may be an
indication of upper
motor neuron disease
or spinal cord
disorders. The
presence of these
reflexes should
warrant further
examinations by MRI.

11. • Neurovascular
examination
Distal pulses are
assessed to ensure
adequate perfusion of
all extremities.

12. Radiologic assessment
• Essential
radiographs
36 inch full
casette standing
radiographs in PA
• LAT
• Left and right
bending
radiographs with
the patient
positioned supine.

13. Optional radiographs
• Fulcrum bending radiographs. This method
of flexibility assessment provides a good
prediction of postoperative outcome for
main thoracic curves, is highly reproducible,
and can be a guide to fusion level
determination.
• Traction radiograph under general
anaesthesia. This method of flexibility
assessment provides a good prediction
of prediction of outcome of both thoracic
and lumbar curves, and can be a guide to
fusion level determination. However, it
can only be carried out during surgery.

14. Measuring Cobb angles

15. • In the lateral X-ray, Cobb
angles are measured in a
more uniform fashion in
the following way:
- A) T2-T5
- B) T5-T12
- C) T10-L2
- D) L1-S1
• In the case of a severe
kyphotic deformity an
additional measurement of
maximal kyphosis can be
used. The superior end
plate is used for the
proximal end vertebra while
the inferior end-plate is
used for the distal end-
vertebra in order to
measure out the area of
maximal kyphosis.

16. • Determination of stable and
neutral vertebra
Central Sacral Vertical Line
(CSVL) is vertical line
bisecting the sacrum.
• Stable vertebra is
determined by the CSVL as
the most cephalad vertebra
that is distal to the end
vertebra that is most closely
bisected by this line.
• The neutral vertebra is
defined as the vertebra that
is not rotated. It is identified
by symmetric pedicles in
the coronal radiograph.

17. 4. Radiographic markers of skeletal maturity
• Risser sign
The Risser sign is a
radiographic depiction of the
iliac apophysis appearance
designating skeletal maturity. It
is on a 0 to 5 scale with 0
indicating skeletal immaturity
and 5 indicating complete
maturity.
• Generally speaking peak height
growth velocity occurs before
the Risser sign emerge.
• Triradiate cartilage
The triradiate cartilage is the
acetabular apophysis which when
present represents a growth
period prior to the peak height
velocity.
• Bone age assessment

18. Generalized radiographic overview
• Curve directionality
Usually in idiopathic
scoliosis the curve
pattern is such that
there is a right thoracic
curve. If there is a left
thoracic curve, this
might be an indication
of a non-idiopathic
scoliosis that might
necessitate further
evaluation.

19. • Pelvic obliquity
Pelvic obliquity is evaluated for
its cause being due to a primary
leg length discrepancy and/or
from the scoliosis.
• Shoulder balance
Shoulder balance is assessed
radiographically to provide an
indication for both preoperative
and postoperative alignment
and balance.

20. Immature patients
• Patients with an open TRC are highly
immature and thus have much growth
remaining. Patients with a closed TRC along
with a Risser zero are more mature but still
undergoing skeletal maturation. Both of these
groups are prone to progressive scoliosis
deformity both within (crankshaft
phenomemon) and outside their fused levels
(adding on phenomenon) of the spine.
• The following three considerations below
should be taken into account.

21. Avoid short fusions in these patients
• Selection of the Lowest Instrumented Vertebra (LIV) in these patients
usually mandates fusion to the neutral and stable vertebra. This will
prevent adding on phenomenon which occurs below a shorter fusion
in immature patients. Adding on phenomenon usually requires
revision surgery to extend the fusion level more distal in the spine
following growth.

22. Consider ASF to remove anterior growth potential
• A preliminary ASF procedure will remove
the anterior growth potential of these
immature patients thus making the
posterior instrumentation and fusion more
definitive. This will also eliminate the
crankshaft phenomenon that often
produces progressive three dimensional
scoliotic deformity in immature patients
treated with a PSF alone.

23. Consider segmental bilateral pedicle screw fixation
to overcome the progressive anterior growth forces
• This is an 11
years, 3
months old
female with a
severe double
major AIS
deformity.
Although her
TRC's are
closed, she is
Risser zero
and
premenarcheal
and thus highly
immature and
at risk for
crankshaft
phenomenon.

24. • She underwent a PSF
from T3-L3 with
segmental bilateral
pedicle screw fixation and
Posterior Column
Osteotomies (PCO's) for
correction of her curves
to 22° and 11°
respectively. At two years
postoperative she is now
skeletally mature without
any signs of crankshaft
phenomenon.

25. Clinical rib hump deformity
• The rib hump deformity deserves
increased attention in the immature
patient. Consideration for optimal rib hump
correction should be made during surgical
correction and this may include performing
a thoracoplasty (costoplasty) in select
cases of severe rib hump deformities.

26. 2. Abnormal neuroaxis
• Most patients with AIS will have a normal
neuroaxis as seen on a total spine MRI.
However patients with atypical curve
patterns, abnormal neurological exams or
unusual history associated with their
scoliosis may have underlying abnormal
neuroaxis. Thus, patients with any type of
these abnormal preoperative conditions
deserve to have a preoperative MRI total
spine screening exam. If a neuroaxis
abnormality is detected on the MRI scan,
consultation with a paediatric
neurosurgeon should be considered.
• Abnormal AIS curve patterns include most
commonly a left thoracic curve or thoracic
hyper kyphosis. Both of these are
notoriously associated with a high risk of
underlying syringomyelia and potential
associated Arnold-Chiari malformation.

27. MRI:
• Any abnormalities to the
neurological exam
warrants a preoperative
screening total spine
MRI.
• Patients with AIS should
otherwise have a normal
history, free of any spinal
pain or rapid progression of
curvature. Patients with
pain out of proportions to
their deformity and/or pain
which awakens them at
night, or prevents them
from pursuing normal
activities is atypical and
warrants preoperative MRI.
This 13 year, 6 months old female
presented with a right thoracolumbar
scoliosis along with pain that often
awakened her at night. CT-scan imaging of
her spine demonstrated a benign osteoid
osteoma tumor located in the lamina of her
L1 vertebra at the apex of her scoliosis.
Thus, her scoliosis was not idiopathic but
caused by this benign bone tumor.

28. 3. Body habitus
• Patients with AIS come in all shapes
and sizes. Overall, the thinner the
patient the more clinical deformity
they will demonstrate on physical
exam. This usually leads to earlier
detection of the scoliosis deformity
than in those patients with a larger
body habitus. In addition, the clinical
manifestations of more severe AIS
curves are noted to a much greater
extent in those patients with a
thinner body habitus. Thus, these
patients may desire operative
correction at a smaller degree of
curvature than those patients with a
larger body habitus which hides the
clinical deformity to a significant
degree.
These two nearly identical Lenke 5CN
thoracolumbar curves presented for
operative correction. The thinner right
patient with the 53° curve demonstrates
more significant truncal deformation than
the left patient with a 52° curve and a
larger body habitus.