CURVE CLASSIFICATION AND NAMING

Scoliosis curves are named by their direction, location, and magnitude. The curve's convex apex indicates its named direction and location, and measurement by the Cobb angle provides its most reliable magnitude (Figure 10.31) (301). If more than one curve exists, the largest degree curve is designated as major and the others minor (Figure 10.32). Curves over 100 degrees are associated with restrictive lung disease.

Rotational deformities complicate bracing and surgical correction. Rotation of the spine is measured using a scoliometer when the child is bending forward (Adams test), and radiographically by pedicle visualization (Nash-Moe x-ray method) or by CT scan (302,303).

HISTORY, PHYSICAL EXAM, AND TREATMENT OVERVIEW

The history and exam for scoliosis patients vary depending upon age and associated diagnosis. Reflexes, strength, sensation, ROM, general posture, muscle bulk, and gait must be examined. Seating systems and assistive devices should be assessed, as improper walker or crutch height, and truncal weakness with poor seating support can impact spinal position in children with disabilities.

A positive family history is particularly pertinent in congenital and idiopathic scoliosis. The presence of back

Risser sign. Likelihood of progression is based on the Risser sign and curve magnitude.

FIGURE 10.30 Risser sign. Likelihood of progression is based on the Risser sign and curve magnitude.

Source: Adapted from Ref. (299). Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am. 1984;66(7):1061-1071.

The Cobb method of measuring curvature in scoliosis. The angle measured is formed by perpendicular lines drawn through the superior border of the upper vertebra and the inferior border of the lowest vertebra of a given curve.

FIGURE 10.31 The Cobb method of measuring curvature in scoliosis. The angle measured is formed by perpendicular lines drawn through the superior border of the upper vertebra and the inferior border of the lowest vertebra of a given curve.

pain may indicate a serious diskitis or tumor, while rapid curve progression, bowel and bladder changes, recent trauma, associated weight loss, muscle weakness, or joint pain can point to other serious primary processes. These might include spinal cord syrinx or tethered cord, spinal fracture, rheumatologic disease, and osteoblastoma. Presence of café au lait spots, webbed neck or low hairline, and hairy patches or skin dimples may lead to recognition of disorders such as Klippel-Feil, spina bifida occulta, or neurofibromatosis.

Excessive height, arm span, or joint hyperextensibility may signal a connective tissue disorder of which scoliosis is only a presenting symptom. Excessive lordosis or kyphosis, LLDs, and limited hip or hamstring ROM could indicate hip dysplasia or an underlying muscle or neurologic disorder such as hemiplegia, herniated disk, spondylolisthesis, or dystrophy.

Pelvic obliquity, asymmetry of the scapula or shoulder girdle, or asymmetry at the waist triangle as the arms hang down should be noted. Asymmetrical prominence of the rib cage of over 7 degrees by scoliometer, seen on forward bending with the feet and palms together (Adam's test), warrants further investigation.

Classification of scoliosis. Scoliosis is classified into general categories by level.

FIGURE 10.32 Classification of scoliosis. Scoliosis is classified into general categories by level.

Source: Adapted with permission from Ref. (296). Staheli L. Practice of Pediatric Orthopedics. 2nd ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2006.

Side bending may help assess the flexibility or rigidity of a curve, which is important when considering treatment options. Decompensation, another sign of scoliosis, can be measured by dropping a plumb line from the C7 spinous process and noting if it passes through the gluteal cleft (normal) or deviates laterally (292).

 
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