Scoliosis is a lateral curvature of the spine. It can be classified based on cause as idiopathic, congenital, neuromuscular, or syndromic. Treatment depends on the type and severity of scoliosis and may include bracing, casting, growing rod instrumentation, spinal fusion, or observation. The goal of treatment is to prevent progression and allow continued spinal and lung growth in children and adolescents.

1. Scoliosis
Presenter: Dr. Kaushik Kr. Dutta
PGT, Dept. of Orthopaedics
Moderator: Dr.A Dutta
Associate Prof., Dept. of Orthopaedics
SMCH, Silchar

2. Introduction
• “scoliosis” - Greek word meaning “crooked.”
• Scoliosis is defined as a lateral deviation of the normal vertical line
of the spine.
• Associated with rotation of the vertebrae.
• Three-dimensional deformity of the spine - sagittal, frontal, and
coronal planes

3. • Non-structural of Postural
• Structural
Classification

4. Classification
• Based on aetiology
1. Idiopathic
2. Congenital
3. Neuromuscular
4. Syndromic or generalised disease

5. Idiopathic
• Infantile
• Juvenile
• Adolescent

6. • The end vertebrae (E) are
those most tilted,
• the apex (A) is vertebra
deviated farthest from the
center of the vertebral
column.
• A neutral vertebra (N) is
one that is not rotated,
• a stable vertebra (S) is one
that is bisected or nearly
bisected by the CSVL
(dotted line), which is
exactly perpendicular to a
tangent drawn across the
iliac crests (solid line).

7. • spinous processes
deviate more and
more to the
concave side
• rib hump in convex
side

8. Postural Scoliosis
• Characteristics of Nonstructural (functional) scoliosis:
• A reversible lateral curve of the spine that tends to be positional or
dynamic in nature.
• No structural or rotational changes in the alignment of the
vertebrae.
• Disappears when the patient is supine or prone or sitting
• Correction of the lateral curve is possible by:
• Forward or side bending. This test is done to determine whether the
curve straightens out as the child bends forward and to identify a
visible, rotational deformity of the rib cage
• Positional changes and alignment of the pelvis or spine.
• Muscle contraction
• By correction of a leg-length discrepancy

10. • Etiology of Nonstructural scoliosis
 Leg length discrepancy: (structural or functional)
Measurable difference because of a dislocated hip,
asymmetric leg or foot postures.
 Habitual asymmetric posture: Sitting with weight shifted
onto one hip or standing with weight primarily supported
on one leg results in asymmetric flexibility and tightness in
soft tissue of the trunk and hips.
 Muscle guarding or spasm from a painful stimuli in the
back or neck,

11. Potential Muscle Impairments
Mobility impairment in structures on the concave side of the
curves.
Impaired muscle performance due to stretch and weakness in the
musculature on the convex side of the curves.
If one hip is adducted, the adductor muscles on that side have
decreased flexibility and the abductor muscles are stretched and
weak. The opposite occurs on the contralateral extremity.
With advanced structural scoliosis, cardiopulmonary impairment
may restrict function.
• Potential Sources of Symptoms
Muscle fatigue and ligamentous strain on the side of the convexity
Nerve root irritation on the side on the concavity

12. Structural scoliosis

13. INFANTILE IDIOPATHIC
SCOLIOSIS
• Younger than age 3 years
• Boys > girls,
• Primarily thoracic and convex to the
left.
• Asso with Mental deficiency, CDH,
plagiocephaly, congenital heart defects
• Self-limiting and spontaneously resolve
(70% to 90%)

14. INFANTILE IDIOPATHIC
SCOLIOSIS
• Curve Progression
• Resolving –
• Age < 1 year, smaller curves,
• No compensatory curves
• Asso with plagiocephaly or other
moulding abnormalities
• Progressive -
• Compensatory or secondary curves
develop,
• > 37 degrees by Cobb Method

15. INFANTILE IDIOPATHIC
SCOLIOSIS
• Mehta – 1. Rib Vertebral Angle
Difference
(<20° - resolving)
2. Two phase radiographic appearance

16. Phase 1: rib head on convex side does not overlap vertebral body.
Phase 2: rib head on convex side overlaps vertebral body.

17. JUVENILE IDIOPATHIC
SCOLIOSIS
• Between the ages of 4 and 10 years
• Right Thoracic curves
• 12% - 21% of idiopathic
• Female-to-male ratio is 1 : 1 btwn 3
to 6 yrs of age, 4 : 1
from 6 to 10 yrs of age, 8
: 1 at 10 years of age.

18. ADOLESCENT
IDIOPATHIC SCOLIOSIS
• Child > 10 years of age but before
skeletal maturity
• Proposed etiological factors,
(1)genetic factors,
(2)neurological disorders,
(3) hormonal and metabolic dysfunction,
(4) skeletal growth,
(5) biomechanical factors, and
(6) environmental and lifestyle factors.

19. ADOLESCENT
IDIOPATHIC SCOLIOSIS –
Natural History
1. Prevalence
2. Progression of curve
3. Problems in adult life

20. Progression of curve

21. Problems in adult life
(1)back pain,
(2)pulmonary function,
(3)psychosocial effects,
(4)mortality, and
(5)curve progression.

22. PATIENT EVALUATION
• History,
• Complete physical and neurological
examinations, and
• Radiographs of the spine

23. History
• Backache
• Menarchal status
• Parental height
• Family history

24. Physical examination
• Serial measurement of height
• Inspection of the spine - hair patches, or
hemangiomas or café au lait spots
• Asymmetry of the shoulder, scapula,
ribs, and waistline
• Spinal balance, hypokyphotic in sagittal
plane
• Adams forward bending test
• Limb lengths

26. Adams forward bending test

27. Adams forward bending test

28. Scoliometer
• < 7 degrees is normal

29. RADIOGRAPHIC
EVALUATION
• Posteroanterior and lateral radiographs
• Right and left bending films, traction films,
fulcrum bending films, or push prone radiographs
– flexibility
• Stagnara - eliminate rotational component of the
curve.
• Radiographic parameters - to assess maturity.
Hand and wrist and development of the iliac
apophysis (Risser sign), triradiate cartilage, olecra-
non apophysis ossification, and digital ossification
• Peak height velocity (PHV) - better

30. Stagnara derotation views

31. MEASUREMENT OF
CURVES
• Cobb method

32. VERTEBRAL ROTATION
• Nash and Moe
• Perdriolle and Vidal

33. Nash and Moe

34. Perdriolle torsion meter
For measuring vertebral
rotation

35. SAGITTAL BALANCE
• Plumb line or sagittal vertibral axis

36. Assessment of Vertebral
Alignment and Balance
• The plumb: line is a
vertical line drawn
downward from the
center of the C7 vertebral
body, parallel to the
lateral edges of the
radiograph
• CSVL :is a roughly
vertical line that is drawn
perpendicular to an
imaginary tangential line
drawn across the top of
the iliac crests on
radiographs. It bisects
the sacrum.

37. • CORONAL BALANCE
is evaluated by
measuring the distance
between the CSVL and
the plumb line
• greater than 2 cm is
abnormal
• SAGITTAL BALANCE is
evaluated by measuring
the distance between the
posterosuperior aspect
of the S1 vertebral body
and the plumb line

38. Sagittal vertical axis
(SVA)

39. CURVE PATTERNS
• PONSETI AND FRIEDMAN
CLASSIFICATION
1. Single major lumbar curve
2. Single major thoracolumbar curve
3. Combined thoracic and lumbar curves
(double major curves)
4. Single major thoracic curve
5. Single major high thoracic curve
6. Double major thoracic curve*

41. KING CLASSIFICATION
Type Characteristics
Type I Lumbar curve is larger than the thoracic curve or nearly equal,
but the lumbar curve is less flexible on side bending
Type
II
A combined thoracic and lumbar curve and thoracic curve is
larger than or equal to the lumbar. On supine side-bending
radiographs, the lumbar curve is more flexible than the thoracic
curve
Type
III
Thoracic scoliosis with the lumbar curve not crossing the midline
Type
IV
Single long thoracic curve, with L4 tilted into the curve and L5
balanced over the pelvis
Type
V
A double structural thoracic curve. The first thoracic vertebra is
tilted into the concavity of the upper curve, which is structural.
An elevation of the left shoulder is a frequent finding. There is an
upper left thoracic rib hump and a lower right thoracic rib
prominence

42. LENKE CLASSIFICATION
(1)Identification of the primary curve,
(2)Assignment of the lumbar modifier,
and
(3)Assignment of the thoracic sagittal
modifier

43. LENKE CLASSIFICATION

44. LENKE CLASSIFICATION

45. Classification
of neuromuscular
disorders causes
of scoliosis

46. Cerebral palsy
A and B, Group I double curves with thoracic and lumbar component and little
pelvic obliquity. C and D, Group II large lumbar or thoracolumbar curves with
marked pelvic obliquity

47. Congenital scoliosis
• Classification
1. Failure of formation
1. Partial failure of formation (wedge vertebra)
2. Complete failure of formation (hemivertebra)
2. Failure of segmentation
1. Unilateral failure of segmentation (unilateral
unsegmented bar;
2. Bilateral failure of segmentation (block vertebra;
3. Miscellaneous

48. Congenital scoliosis
Defects of formation. A, Anterior central defect. B, Incarcerated
hemivertebra. C, Free hemivertebra. D, Wedge vertebra. E, Multiple
hemivertebrae.

49. Congenital scoliosis
Block vertebra. Unilateral and unsegmented bar with
contralat- eral hemivertebra

50. Treatment of infantile idiopathic
scoliosis
• 70-90% natural favourable histroy- no active
treatment required
• initial curve <250, RVAD<200 –observation with
radiographic followup every 6 months
• Most resolving curves corect by 3 yrs age
• Follow up even after resolution till adolescent

51. Treatment options for progressive
curves
• Serial casting + bracing+ later fusion
• Preoperative traction + later fusion
• Growing rod or vertical expandable prosthetic
titanium rib( VEPTR) instrumentation without fusion

52. Casting and bracing
• Best results if casting started < 20 months of age and
<600 curves
• Cast change every 2-4 months
• Once corrected to < 100 use custom moulded brace

56. Operative treatment
• Indicated if curve is severe or increases despite use of
an orthosis/casting
• Principle of surgery- surgery should not only stop
progression of the curve but also allow continued
growth of the thorax and development of the
pulmonary tree
• Fusionless instrumentation techniques are
preferred(VEPTR)
• If surgical fusion is necessary- short ant and post
artrodesis including only the primary curve
• Combined fusion necessary- to prevent crankshaft
phenomenon

57. Treatment of juvenile idiopathic
scoliosis
• Curves <200 – observation+ examination and
standing PA radiograph every 4-6 months
• Evidence of progression on radiograph- change in
curve 5-70- brace treatment
• Curve not progressing- observation till skeletal
maturity

58. SURGEON VS ORTHOTIS
Restlessness with Over-enthusiastic
Tubular vision syndrome ! Proponent of Brace
Breathless expectancy on BracesInborn Nihilism in Conservatism ?
Balance
EVIDENCE
BASED
MEDICINE
UNREALISTICUNREALISTIC
PRAGMATISM

59. Principle: Three point fixation
To prevent curve progression during high risk period of skeletal growth.
MILWAUKEE BRACE

60. Brace teatment (TLSO)
Boston brace Charleston bending brace

61. Evaluation of Brace Treatment of Juvenile Idiopathic
Scoliosis by the Rib-Vertebral Angle Difference
(RVAD)
• If the RVAD values progress above 10 degrees
during brace wear, progression can be expected.
• If the RVAD values decline as treatment continues,
part-time brace wear should be adequate.
• Those patients with curves with RVAD values near
or below 0 degrees at the time of diagnosis
generally will require only a short period of full-
time brace wear before part-time brace wear is
begun.

62. Operative treatment
Important consideration-
• Expected loss of spinal height, Limited
chest wall growth and lung
development
• Crankshaft phenomenon

63. FIGURE
Crankshaft phenomenon.
A, Spine with scoliosis. B, Despite solid posterior fusion, continued
anterior growth causes increase in deformity.

64. Surgical options
Child <8yrs and small-
 growing rod instrumentation-
• principle of surgery – posterior instrumentation that
is sequencially lengthened to allow longitudinal
growth while still attempting to control progressive
spinal deformity.
• surgery is required every 6 months to lengthen the
construct
• A TLSO is used for first 6 months
• Dual growing rod- effective in controlling severe
spinal deformities and allowing spinal growth, apical
fusion doesn’t become necessary in course of Rx

65. Guided growth and physeal stapling
Principle of surgery- interertebral stapling is used to
produce a tethering effect on the convex side of the
spine. This tether theoritically will allow for continued
growth on the concave side of the spine deformity and
gradual correction of the deformity with growth
Indications –
1. Age <13 yrs in boys and 15 yrs in girls
2. Skeletal maturity of Risser grade 0 or 1, with 1yr of
growth remaining by wrist bone age
3. Minimal rotation of both thoracic and lumbar curves
of 450 and flexibility to < 200 and a sagittal thoracic
curve of 400 or less

66. • Child age >9/10yrs or unable to coperate with
demand of growth rod-
 Instrumentation and spinal fusion

67. Treatment of adolescent idiopathic
scoliosis
• Nonoperative treatment
1. observation- young patient with mild curve <200
2. orthotic treatment-
 progression of curve beyond 250
 Curve of 30-400 in skeletally immature
SRS optimal inclusion criteria for bracing:
• Age 10yrs or older
• Risser grade 0-2
• Primary curve angle 25-400
• No prior treatment
• If female either premenarchal or less than 1 yr post
menarchal
3.Underarm cast- seldom is used now a days

68. Indications for operative treatment for
adolescent idiopathic scoliosis
• Increasing curve in growing child
• Severe deformity (>50 degrees) with
asymmetry of trunk in adolescent
• Pain uncontrolled by nonoperative
treatment
• Thoracic lordosis
• Significant cosmetic deformity

69. Surgical options
• Posterior surgeries
1. Facet fusion- Moe/Hall technique
2. Posterior spinal instrumentation-
 multiple hook segmental instrumentation
pedicle hook implantation
transverse process hook implantation
lamina hook implantation
sublaminar wires
sublaminar cables

70.  Pedicle fixation- lumbar pedicle screw
thoracic pedicle screw
For rigid curves-
 Halo-gravity traction
 temporary distraction rod
 Anterior release of thoracic and lumbar spine
 Osteotomy in complex spinal deformity
 Posterior thoracic vertebral column resection
For posterior rib prominence(cosmetic purpose)
Posterior thoracoplasty
Concave rib osteotomies

71. • Anterior surgeries
 Disc excision
 Anterior instrumentation of a thoracolumbar
curve with CD horizon legacy dual rod
instrumentation
 Anterior thoracoplasty
• Other surgeries-
 Video assisted thoracoscopy-
anterior release
discectomy
CD horizon eclipse spinal insrumentation

72. FIGURE
41-32 A, Skin incisions for posterior fusion and autogenous bone graft. B, Incisions over
spinous processes and interspinous ligaments. C, Weitlaner retractors used to maintain
tension and exposure of spine during dissection.

73. FIGURE
41-33 A and B, Cobb curets used to clean facets of ligament
attachments.

74. Moe technique of thoracic facet fusion.

75. FIGURE
41-35 A and B, Moe technique of lumbar facet
fusion.

76. FIGURE
41-36 A-C, Hall technique of facet fusion

77. Posterior spinal instrumentation
• Goal is to correct the deformity as much as possible
and to stabilized the spine in the corrected position
while the fusion mass become solid
• In 1962 Harrington first introduced the effective
instrumentation system for scoliosis
• For more than 30 yrs harrington distraction rod
combined with posterior arthrodesis and
immobilization in cast or brace for 6-9 months
remained standard tretment
• Later it is replaced by multiple hook, sublaminar
wire and pedicle screw

78. Disadvantage of advantage of newer
harrington system instrumentation
• Correction is achieved with
distraction so efficiency of
correction is decreased
• Traction forces are applied at
the end of the construct
where the hooks are seated.
If loads exceeds the strength
of lamina fracture and loss of
correction can result
• With distraction spine is
elongated and loss of sagittal
contour occurs
• Distraction does not deal
with rotational component
• Provide multiple point of
fixation to the spine and
apply compression ,
distractionand rotation
forces through same rod
• Donot require any post
operative immobilization
• Better coronal plane
correction and better control
in sagittal plane
• Better transverse plane
correction with pedicle
screw
• Hypokphosis in thoracic
spine reduced and lumbar
lordosis preserved

79. Effects of distraction rod in lumbar spine. If contouring for lordosis is
inadequate, lumbar spine can be flattened by distracting force. Also note
kyphotic deformity just superior to distraction rod.

80. Correction maneuvres of spinal deformity
• Distraction on the concave side of a thoracic curve
will decrease scoliosis and thoracic kyphosis
• Compression applied on the covex side of a lumbar
curve will correct scoliosis and maintain lumbar
lordosis
• Translating the apex of the curve in to a more normal
position- rod derotation maneuver
• Pure translation using sublaminer wires or screw on
cocave side
• Cantilever maneuver
• Direct vertebral rotation with pedicle screw

81. Basic principles of fusion level and hook site
placement
• AP, lateral and bending films are necessary
• In the saggital plane all pathological curves must be included.
Instrumentation should not be stopped in the middle of a
pathological saggital curve such as thoracolumbar junctionl
kyphosis. The upper hook should not stopped at the apex of
thekyphosis proximally
• in the transverse plane the instrumentation should extend to a
rotational neutral vertebra
• Instrumentation should be stopped at the level above disc space
neutralization, as determined on bending films as long as this
level does not conflict with the saggital and transverse plane
requirement
• The distal level should fall within the stable zone of harrington

82. Basic principle of the force generated by hook
and its action on sagittal plane
1. Distraction forces ( forces directed away from the
apex of the curve ) decrease lordosis or contribute to
kyphosis
2. Compression forces (towards the apex of the curve)
decrease kyphosis or creat lordosis
3. To create kyphosis the concave side must be
approached first
4. To create lordosis the convex side must be
approached first and forces must be directed
towards the apex of the curve
5. At the thoracolumbar junction , distractive forces
should not be applied

83. a. Facectomy b. french bender c.forcep rocker used to seat the rod in implant

84. Set screw insertion in to the hook using Beale rod reducer

85. Deformity correction by CD Horizon
Legacy spinal deformity system. a,.rod derotation b. rod bending

86. Rod compression and distraction, stabilization, and final tightening for CD Horizon
Legacy spinal deformity system (see text). Decortication, rod contouring, and
reduction.

87. Pedicle screw fixation
FIGURE 41-80 Pedicle channel classification (see text). (From Watanabe K, et al: A
novel pedicle channel classification describing osseous
anatomy, Spine 35:1836, 2010.)

88. Basic steps in identifying and placing a
pedicle screw
1. Clearing the soft tissue
2. Exposing the cancellous bone of the pedicle canal by
decortication at the intersection of the base of the
facet and middle of the transverse process
3. Probing the pedicle
4. Verifying the four walls of the pedicle canal by
probing or obtaining radiographic confirmation
5. Tapping the pedicle
6. Placing the screw

89. Zindrick pedicle approach zone
Common entry point in lumbar spine
Position of pedicle in sacrum

95. Complications of posterior scoliosis
surgery
Early complications late complications
1. Neurological injury 1. pseudoarthrosis
2. Infection 2. loss of lumbar lordosis
3. Ileus 3.crankshaft phenomenon
4. Atelectasis 4. sup. Mesenteric artery
5. Pneumothorax syndrome
6. Dural tear 5. trunk decompensation
7. Wrong levels 6. late infection
8. Urinary complications
9. Vision loss

96. Treatment options for neuromuscular scoliosis
• Nonoperative- observation/orthotic
• Operative-
 Luque rod instrumentation and sublaminar
wiring
 Sacropelvic fixation-
 galveston sacropelvic fixation
 Unit rod instrumentation with pelvic fixation
 Iliac fixation with iliac screws
 S2 iliac lumbopelvic screw placement

97. Indications for Correction and Posterior Spine
Fusion in Patients with Poliomyelitis
• Collapsing spinal deformity because of marked paralysis
• Progressive spinal deformity that does not respond to
nonoperative treatment
• Reduction of cardiorespiratory function associated with
progressive restrictive lung disease
• Decreasing independence in functional activities because
of spinal instability that necessitates use of the upper
extremities for trunk support rather than for table-top
activities
• Back pain and loss of sitting balance associated with
pelvic obliquity, which frequently causes ischial pain and
pressure necrosis on the downside of the gluteal region

98. Treatment of Congenital Scoliosis
• Prevention of future deformity
In situ fusion
• Correction of deformity—
Gradual Hemiepiphysiodesis and
hemiarthrodesis
Growing rod nonfusion
Vertical expandable prosthetic titanium rib
• Correction of deformity—
acute Instrumentation and fusion
Hemivertebra excision
Osteotomy

99. Posterior fusion without instrumentation
• Allows for stabilization of a curve
• Idealy done early for small curve to prevent
the curve from becoming unaaceptably large
• One level cephalad and one level cudad to the
involved vertebra are included in fusion

100. Posterior fusion with instrumentation
• Slightly more correction can be obtained
• Rate of pseudoarthrosis is low
• Post operative cast / bracing least unpleasant
• Disadvantage are paralysis and infection

101. Combined anterior and posterior fusion
• To treat saggital plane problems
• To increase the flexibility of the scoliosis by
discectomy
• To eliminate the anterior physis to prevent
bending or torsion of the fusion mass with
further growth
• To treat curves with a significant potential for
progression

102. Combined ant-post convex
hemiepiphysiodesis
• Used for curves that are result of failure of
fusion
• Correction of deformity relies on the future
growth of the spine on the concave side
• Best for treating single hemivertebra that
have not resulted in alarge curve at the time
of surgery
• Appropriate in children <5 yrs with
 Progressive curve of < 500, with 6 segments or
less,with concave growth potential and no
pathological congenital kyphosis /lordosis

103. Hemivertebra excision
• It can produce immediate correction of a
congenital spine deformity
• It will remove the cause of and prevent
further worsening of the deformity
• Is reserved for patients with pelvic obliquity
or with fixed lateral translation of the thorax
that can not be corrected by other means

104. Thank You