Chapter 68 Scoliosis
PATHOPHYSIOLOGY
Scoliosis, a frequently occurring orthopedic problem, is the lateral curvature of the spine with a Cobb angle of more than 10 degrees accompanied by vertebral rotation. It can occur anywhere along the spine. Curvatures in the thoracic area are the most common, although curvatures of the cervical and lumbar areas are the most deforming. There are two basic forms of scoliosis: functional and structural. Functional scoliosis is secondary to a preexisting problem such as poor posture or unequal leg length. This form of scoliosis can be corrected through exercises or the use of shoe lifts. Structural scoliosis results from the congenital deformity of the spinal column. This condition often occurs in children with myelomeningocele and muscular dystrophy. Scoliosis is also seen in children with cerebral palsy and osteogenesis imperfecta. The structural form of scoliosis can be classified into three basic types: (1) infantile, which occurs during the first year of life (more than 20% of affected children have spontaneous resolution); (2) juvenile, which occurs between 5 and 6 years of age (bracing is used for management); and (3) adolescent, which is not evident until 11 years of age (when skeletal maturation occurs). Management of scoliosis may include nonsurgical and/or surgical methods. Most spinal curvatures do not progress more than 20%. The curvature is flexible initially and becomes rigid with age.
CLINICAL MANIFESTATIONS
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and/or ranges of laboratory and diagnostic tests.
1. Forward bending test, or Adam’s position—to assess inequality of flank and ribs (screening test)
2. Cobb diagnostic method—to assess angle of curvature on radiographic studies
3. Anteroposterior and lateral radiographic studies of spine—to evaluate curvature of spine
4. Three-dimensional computed tomography—to assess for axial rotation of the spine
5. Magnetic resonance imaging—to assess for intraspinal pathology
Preoperative Tests
1. Complete blood count—to assess for anemia
2. Blood chemistry analysis—to assess for electrolyte imbalances
3. Type and cross-match for blood transfusions
4. Coagulation studies—to assess for deficiency in clotting factors
5. Radiography of skull—to assess for area of spinal curvature
6. Pulmonary function tests—to assess for pulmonary complications.
7. Arterial blood gas values—to assess for pulmonary complications
MEDICAL AND SURGICAL MANAGEMENT
Curves of less than 20 degrees require evaluation every 3 to 12 months. If the curve progresses, several corrective devices can be used to stop its progression. The Milwaukee brace is used for treatment of lateral curvature of 20 to 40 degrees; the brace consists of neck ring and pelvic girdle, and it must be worn 23 hours a day until curvature is corrected. The thoracolumbar-sacral orthosis (TLSO, or the Boston brace) is a molded plastic jacket that comes up to beneath the underarms and is worn 20 hours a day. A Cheneau orthosis can also be used. The Charleston bending brace is worn at night.
