A 12-year-old girl presents to the office after a routine school screening. She was told that she has an abnormal curvature of her spine, and she notes an unpleasant hump on the right side of her back. She is found to have a right sided prominence, shoulder height differences, and lateral curvature of her spine on examination (Figures 91-1 and 91-2). Neurological examination is normal. PA and lateral x-rays are taken, and the patient is referred to a Pediatric Orthopedic surgeon for evaluation and management.
FIGURE 91-2
Typical scoliosis deformities that are seen on posterior clinical examination of the same girl as in Figure 91-1. Note the assymetry of the scapulae and the waist contours. The curvature of the spine is visible along with a slightly higher right shoulder too. (Used with permission from David Gurd, MD.)
Scoliosis is a lateral curvature of the spine that is greater than 10 degrees in the coronal plane (Figure 91-3). It is often associated with rotational changes and hypokyphotic spinal deformity (flat thoracic spine when viewed from the side).1
FIGURE 91-3
Example of rotational deformity that occurs with scoliosis. Notice how the vertebral body rotates out toward the apex and convexity of the curve. The majority of the rotation is located nearest to the apex, less away from the apex. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2012. All Rights Reserved.)
Overall incidence in the population is 2 to 3 percent, with 0.1 to 0.3 percent of the population developing significant curves exceeding 20 degrees.2
Scoliosis is classified as:
Congenital—Arising from congenital (as an infant) vertebral anomalies such as wedged vertebrae, hemivertebrae, and fused/unsegmented vertebrae.
Infantile Idiopathic Scoliosis—Scoliosis which is present between birth and 3 years of age without congenital change. This comprises 4 percent of all idiopathic scoliosis cases.3
Juvenile Idiopathic Scoliosis—Scoliosis which develops between 4 and 10 years of age. This comprises 10 to 15 percent of all idiopathic scoliosis cases.4
Adolescent Idiopathic Scoliosis (AIS)—Scoliosis which develops between 10 and 18 years of age. This is by far the most common form of scoliosis.
The vast majority of cases are idiopathic, as is the case with nearly all adolescents presenting with deformity.
Numerous theories have been proposed for infantile and juvenile cases, including intra-uterine molding, lying infants on their backs, and genetic predisposition.5
Patients with scoliosis are typically asymptomatic. They may complain of intermittent back pain, but not more commonly than children without scoliosis. We do not believe that the scoliosis causes back pain unless the deformity is quite severe (Figures 91-4 and 91-5).6 Patients and family members may report a deformity of the spine (curvature), rib cage (hump), shoulders (uneven), or pelvis (waist line asymmetry).
The vast majority of curves are right-sided, meaning that the spine curves to the right when the patient is viewed from the back. Often there is a rib prominence noted when the patient bends forward. A curvature of the spine is more evident on forward bending. Patients will often notice unequal shoulder and/or iliac crest (pelvis) heights (Figure 91-6).
Neurologic deficit is uncommon, but it must be checked as scoliosis can be caused by neurological abnormalities. If there is a concern, an MRI can be helpful for assessment.
FIGURE 91-5
Severe scoliosis deformity of same patient in Figure 91-4 from lateral view. Note how the upper spine is almost horizontal. (Used with permission from Richard Usatine, MD.)
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