Bone Health

Scoliosis is defined as a frontal plain curvature of the spine greater than 10° with structural rotation at the apical segment. The incidence of adult scoliosis is estimated to be between 4% to 8%. Scoliosis in adults can be the consequence of a process that began before skeletal maturity (adolescent idiopathic scoliosis) or the scoliosis can arise, "de novo", in adult life secondary to osteoporosis, osteomalacia or latrogenic causes such as multilevel decompression for spinal stenosis and degenerative changes. This article will focus primarily on the resulting spinal deformity that began to develop before skeletal maturity. However, the principles apply to other forms of adult scoliosis. Treatment philosophies (goals) in adult scoliosis differ markedly from scoliosis in the skeletally immature group. When evaluating and treating scoliosis in the adolescent population, the emphasis is on preventing the complications that occur from scoliosis in adult life. Whereas, in adult scoliosis, since the scoliosis deformity has already occurred, treatment is directed at managing rather than preventing the complications of scoliosis.
Sunday U. Ero, M.D. and Peter Blessey, M.D. Jacksonville Medicine / June, 1999

Kono et al JOS 2000 8(1) 19-26

Patterns of presentation of congenital scoliosis Mohanty & Kumar JOS 2000 (2) 33-37

Acta Orthop Scand. 2001 Dec;72(6):621-5. Curve characteristics in monozygotic twins with adolescent idiopathic scoliosis: 3 new twin pairs and a review of the literature.van Rhijn LW, Jansen EJ, Plasmans CM, Veraart BE. Department of Orthopaedic Surgery, University Hospital Maastricht, The Netherlands. lvr@sort.azm.nl Most authors state that there is strong evidence for a genetic origin of adolescent idiopathic scoliosis (AIS). This conclusion is mainly based on the fact that the rate of concordance for AIS in monozygotic twins is significantly higher than that in dizygotic twins. However, it is of interest to determine whether all elements of scoliosis formation are genetically predetermined. If this were the case, there would perhaps be less place for closed treatment. We surveyed the literature for monozygotic twin pairs in which both members suffered from idiopathic scoliosis and added 3 pairs from our own patient group. The total group consisted of 32 twin pairs. We found that gender, direction of the convexity, the level of the apex and the kyphotic angle were determined more by genetic factors than the lateral Cobb angle of the scoliotic curve. This suggests that variations in the environment may affect the curve patterns in monozygotic twins.

The timing of spinal fusion in adolescent idiopathic scoliosis Mohanty et al JOS 2001 9(2) 7-14

Acta Orthop Scand. 2001 Dec;72(6):615-20. Treatment of idiopathic scoliosis with CD-instrumentation: lumbar pedicle screws versus laminar hooks in 66 patients.Wimmer C, Gluch H, Nogler M, Walochnik N. Department of Orthopedic Surgery, University of Innsbruck, Austria. We studied whether the pedicle screw is better than laminar hooks for fixation of the lumbar spine in the treatment of idiopathic scoliosis. 66 consecutive patients with idiopathic scoliosis (King I and II) were studied retrospectively. Group S included 33 patients (25 females) treated with pedicle screws. Their mean age at operation was 17 (13-54) years. Group H included 33 patients (30 females) treated exclusively with hooks. Their mean age at operation was 16 (1140) years. The preoperative mean angles of the thoracic curve in group S was 66 (42.115) degrees, and in group H 65 (42-121) degrees. The lumbar curve averaged 46 (20-85) degrees in group H and 53 (33-86) degrees in group S. All patients were fused only posteriorly with Cotrel-Dubousset instrumentation and an autogenic bone graft. The mean follow-up time was 4 (2-7) years. Mean correction of the thoracic curve was 45% in group S and 50% in group H. The lumbar curve was corrected by 50% in group S and 51% in group H. Loss of correction of the thoracic curve occurred in 5% in group S and 6% in group H and of the lumbar curve in 3% in group S and 10% in group H (p = 0.04). Group S better maintained the correction of the lateral tilt of the uninstrumented segment adjacent to the fusion (p = 0.04). Derotation, according to Perdriolle, in the distal segment adjacent to the fusion was 6% in group S and 2% in group H. We found no difference between correction of the thoracic and lumbar curves using pedicle screws and laminar hooks in the lumbar spine. Pedicle screws better maintained the correction of the lumbar curve and the lateral tilt in the distal segment adjacent to fusion.

Acta Orthop Scand. 2002 Jun;73(3):277-81. Links Changes in curve pattern after brace treatment for idiopathic scoliosis.van Rhijn LW, Plasmans CM, Veraart BE. Department of Orthopaedic Surgery, University Hospital Maastricht, The Netherlands. lvr@sort.azm.nl We studied whether thoracic Boston brace treatment changes the King type of scoliotic curves in a group of 50 patients with adolescent idiopathic scoliosis. Bending radiographs showed more flexibility of the lumbar curves than that of the thoracic curves. However, after initial application of the brace, the mean lumbar correction in degrees was less than the mean thoracic correction. After brace treatment we found a slight statistically significant increase in the mean lumbar curve, but no significant change in the mean thoracic curve. In 7 of our patients, we found a change in the King classification which seemed to be related to insufficient lumbar correction at the start of brace treatment. When classifying idiopathic scoliosis, one should bear in mind that the result may be temporary because scoliosis is a dynamic process. A change in curve type can occur during brace treatment.

Acta Orthop Scand. 2002 Aug;73(4):481-2. Modified unit rod technique in scoliosis surgery--a case report.Csernátony Z, Gáspár L, Jónás Z, Szepesi K. Department of Orthopaedic Surgery, University of Debrecen, Medical and Health Science Center, Hungary.

J Orthop Surg (Hong Kong). 2002 Dec;10(2):144-51. Spinal fusion and instrumentation for paediatric neuromuscular scoliosis: retrospective review.Thacker M, Hui JH, Wong HK, Chatterjee A, Lee EH. Department of Orthopaedic Surgery, National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore. PURPOSE: A retrospective study was conducted to review the surgical results among 24 patients with neuromuscular scoliosis, who were treated with spinal instrumentation and fusion at the Department of Orthopaedic Surgery, National University Hospital, Singapore between March 1993 and December 1998. METHODS: We examined complete hospital records of patients who had scoliosis due to aetiologies such as spinal muscular atrophy, cerebral palsy, Duchenne muscular dystrophy, and congenital myopathies. The mean age of patients was 10.6 years (range, 6-14 years) and the mean follow-up duration was 5.5 years. RESULTS: 18 patients had posterior surgery alone, whereas 4 had an anterior release with posterior instrumentation, and 2 had an anterior fusion with instrumentation. The mean length of stay in the intensive care unit was 2 days and the mean duration of hospital stay was 11 days. The mean correction in scoliosis angle ranged from 75.6 degrees to 25.7 degrees. All patients could at least sit without support postoperatively. The one-second forced expiratory volume and forced vital capacity were, in general, maintained throughout the follow-up. There were 2 major complications and 2 minor ones; these were pseudarthrosis with rod breakage requiring revision, deep infection necessitating hardware removal, superficial infection that responded to antibiotics, and urinary tract infection requiring 3 weeks of antibiotic treatment. There were no deaths or any neurological complications after instrumentation. CONCLUSION: Spinal stabilisation and fusion in children with neuromuscular scoliosis is a safe and effective treatment modality. The effect of surgery on long-term pulmonary function, however, remains controversial and needs to be addressed

J Orthop Surg (Hong Kong). 2003 Dec;11(2):202-6. Degenerative spondylolisthesis at the L4-L5 in a 32-year-old female with previous fusion for idiopathic scoliosis: a case report.Winter RB, Silverman BJ. University of Minnesota, Minneapolis, MN, USA. We report a case of degenerative L4-L5 spondylolisthesis in a 32-year-old female who had undergone thoracic (lower level T12) fusion as a teenager. All other levels in the lumbar spine were normal on magnetic resonance imaging. Subsequent fusion of L4-L5 led to improvement in function and alleviation of pain for more than 4 years. The possible relationship between the previous fusion and degenerative spondylolisthesis is discussed.

Degenerative spondylolisthesis at the L4–L5 in a 32-year-old female with previous fusion for idiopathic scoliosis: A case report Winter & Silverman JOS 2003 11(2) 202-206

Use of epidural analgesia for pain management after major spinal surgery Kumar et al JOS 2003 11(1) 67-72

The management of congenital scoliosis requires a systematic approach with careful attention to detail. Any fortuitous diagnosis of vertebral anomalies in infancy, even if there is no signifi- cant scoliosis at that time on x-ray, requires frequent clinical and radiographic follow-up to detect progression. The presence of associated anomalies of the spinal cord, the kidneys and the heart should be evaluated by MRI, renal ultrasound or IVP, with cardiology evaluation as indicated. Curve progression or severe vertebral anomalies known to cause curve progression require immediate treatment to prevent deformity. Significant thoracic deformity, especially in a patient with thoracic insufficiency syndrome, is best treated with expansion thoracoplasty. The patient with congenital scoliosis requires a long term commitment to care with frequent orthopaedic follow-up throughout the growing years along with routine pulmonary function assessment once the patient is able to cooperate with testing. (Full text)
Med Sci Monit, 2004; 10(5): RA104-110 Nusret Kose, Robert M. Campbell Jr

Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series
Mark W Morningstar1 , Dennis Woggon2 and Gary Lawrence3 1Director of Research, Pettibon Biomechanics Institute 3416-A 57th St Ct. NW; Gig Harbor, WA 98335, USA 2Director, CLEAR Institute; 437 North 33rd Ave; St. Cloud, MN 56303, USA 3Director, Lawrence Chiropractic Clinic, 13961 60th St North; Stillwater MN, 55082, USA
BMC Musculoskeletal Disorders 2004, 5:32 doi:10.1186/1471-2474-5-32
Conclusions: The combined use of spinal manipulation and postural therapy appeared to significantly reduce the severity of the Cobb angle in all 19 subjects. These results warrant further testing of this protocol.

United States Preventive Services Task Force: Screening for Idiopathic Scoliosis in Adolescents: Recommendation Statement: United States Preventive Services Task Force. The Internet Journal of Pediatrics and Neonatology. 2004. Volume 4 Number 1.
Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis