Course

Michele Romano
 Course
Scoliosis Basic concepts
 DEFINITION
Scoliosis is a "three-dimensional deformation
of the spine and trunk“.
It causes a lateral curvature in the frontal plane,
an axial rotation in the horizontal one, and a
disturbance of the sagittal plane normal
curvatures. Kyphosis and lordosis, usually, but not
always, reducing them in direction of a flat back.
 "Scoliosis" must be differentiated from
"functional scoliosis", that is a spinal curvature
secondary to known extraspinal causes (e.g.
shortening of a lower limb or paraspinal muscle
tone asymmetry). It is usually partially reduced
or completely subsides after the underlying
cause is eliminated.
 The term Idiopathic Scoliosis
was introduced by Kleinberg
(1922), and it is applied to all
patients in which it is not
possible to find a specific disease
causing the deformity.
By definition, idiopathic scoliosis
is of unknown origin and is
probably due to several causes.
 The curvature in the frontal plane
(AP radiograph in upright position)
is limited by an 'upper end
vertebra' and a 'lower end
vertebra', taken both as a reference
level to measure the Cobb angle.
Cobb angle is formed by
the lines parallel to the
upper end-plate of the
upper end-vertebra and
the lower end-plate of
the lower end-vertebra
The Scoliosis Research Society (SRS)
suggests that the diagnosis is
confirmed when the Cobb angle is
10° or higher and axial rotation can
be recognized.
Maximum axial rotation is
measured at the apical vertebra.
In approximately 20% of cases, scoliosis is
secondary to another pathological
process. The remaining 80% are cases of
idiopathic scoliosis. Adolescent idiopathic
scoliosis (AIS) with a Cobb angle above
10° occurs in the general population in a
wide range from 0.93 to 12% .
2-3% is the value the most often found in
the scientific literature.
 Approximately 10% of these
diagnosed cases require
conservative treatment.

Approximately 0.1-0.3% require

surgical correction of the
deformity.
Progression of AIS is much more frequently
seen in females. When the Cobb angle is 10
to 20°, the ratio of affected girls to boys is
similar.

When the Cobb angle is between 20 and

30° the ratio of affected girls to boys is 5.4:1

When the Cobb angle is above 30° the ratio

of affected girls to boy is 7:1
 If the scoliosis angle at completion of
growth exceeds a"critical threshold"
(most authors assume it to be between
30° and 50°), there is a higher risk of
health problems in adult life, decreased
quality of life, cosmetic deformity and
visible disability, pain and progressive
functional limitations.
ETIOLOGY
The etiopathogenesis of scoliosis has
not been elucidated.

There are a lot of hypotetic causes.

 The role of genetic factors in the development of spinal axial
disorders is confirmed by the tendency of scoliosis to run in families

Numerous authors indicate that the causes of scoliosis could be a

systemic disorders of, among others, mucopolysaccharide and
lipoprotein synthesis.

In the 1990s a group of researchers proposed that scoliosis

develops as a result of melatonin synthesis disorder.

Other authors have evaluated the possibility that gene variants of

IL-6 and MMPs might be associated with scoliosis and suggests that
MMP-3 and IL-6 promoter polymorphisms constitute important
factors for the genetic predisposition to scoliosis
NATURAL HISTORY
 Idiopathic scoliosis (IS) may develop at any
time during childhood and adolescence. It is
most common in periods of growth-spurt,
between the ages of 6 and 24 months
(infantile), 5 and 8 years (juvenile) and 11
and 14 years of life (adolescent)
 The rate of development of spinal
curvature changes the most rapidly at
the beginning of puberty. According to
the Tanner scale, which assesses tertiary
sex characteristics, this period
corresponds to stage S2 and P2 in girls,
and T2 and P2 in boys
Natural hystory
Natural hystory
 There is a much lower potential for
progression of idiopathic scoliosis after
the spinal growth is complete. In
adulthood IS may intensify as a result
of progressive osseous deformities
and collapsing of the spine
 This phenomenon is reported
especially in scoliosis that is more
severe than 50°, while the risk of
progression starts to increase as
the curve grows above 30°
 Nevertheless, the natural history
of adult scoliosis is not well known
to date, and it is still possible the
progression can have some peak
periods. A "de novo" scoliosis has
been recognized as a possible
form in adulthood
CLASSIFICATION
Cronological Angular Topographic
(Age at diagnosis) (Cobb degrees) ( Apex)

Infantile Low Cervical

0-3 5-15 From Disk - to C6

Juvenile Low to Moderate Cervico – Thorac

3-10 16-24 From Disk C7 to T1

Adolescent Moderate Thoracic

10 -18 25-34 From Disk T2 to T11

Adult Moderate to severe Thoraco-lumbar

18 - 35-44 From Disk T12 to L1

Severe Lumbar
45-59 From Disk L2 to –

Very severe
60 or more
Objectives
 AIMS OF THE TREATMENT
Adolescent Adolescent Infantile and
Idiopathic Idiopathic Juvenile
Scoliosis Scoliosis Idiopathic
Up to 45° Over to 45° Scoliosis

Xray Aims Primary Below Below Below

25° 35° 25°
Secondary Below No Below
35° progression 50°
Main Aims Avoid Improve Reduce
surgery aesthetics disability
and quality and pain
of life
Practical scheme
of treatment
 PAS (Practical Approach Scheme)
Cobb 0-10 + 11- Over
16-20 21-25 26-30 31-35 36-40 41-45 46-50
degrees hump 15 50
Infantile Min Ob6 Ob6 Ob3 SSB SSB SSB SSB SSB PTRB FTRB
Max Ob3 Ob3 PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Juvenile Min Ob3 Ob3 Ob3 SSB SSB SSB PTRB PTRB PTRB FTRB
Max PSE PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Adolescent Min Ob6 Ob6 Ob3 PSE PSE SSB PTRB PTRB PTRB FTRB
0
Max Ob3 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob6 Ob6 Ob3 PSE PSE SSB PTRB PTRB PTRB FTRB
1
Max Ob3 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob8 Ob6 Ob3 PSE PSE SSB SSB SSB SSB FTRB
2
Max Ob6 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob12 Ob6 Ob6 Ob6 PSE SSB SSB SSB SSB FTRB
3
Max Ob6 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min No Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 SSB FTRB
4
Max Ob12 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min No Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 SSB FTRB
4-5
Max Ob12 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
 PAS (Practical Approach Scheme)
Cobb 0-10 + 11- Over
16-20 21-25 26-30 31-35 36-40 41-45 46-50
degrees hump 15 50
Infantile Min Ob6 Ob6 Ob3 SSB SSB SSB SSB SSB PTRB FTRB
Max Ob3 Ob3 PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Juvenile Min Ob3 Ob3 Ob3 SSB SSB SSB PTRB PTRB PTRB FTRB
Max PSE PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Adolescent Min Ob6 Ob6 Ob3 PSE PSE SSB PTRB PTRB PTRB FTRB
0
Max Ob3 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob6 Ob6 Ob3 PSE PSE SSB PTRB PTRB PTRB FTRB
1
Max Ob3 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob8 Ob6 Ob3 PSE PSE SSB SSB SSB SSB FTRB
2
Max Ob6 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min Ob12 Ob6 Ob6 Ob6 PSE SSB SSB SSB SSB FTRB
3
Max Ob6 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min No Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 SSB FTRB
4
Max Ob12 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
Risser
Min No Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 Ob6 SSB FTRB
4-5
Max Ob12 PSE PTRB FTRB FTRB FTRB FTRB FTRB Su Su
 PAS (Practical Approach Scheme) Adult patients
Cob Hump 11- 16- 21- 26- 31- 36- 41- 46- +
Angle + 10 15 20 25 30 35 40 45 50 50

Ob1 Ob1
Adult No pain Min No No No No No No No No
2 2
Ma
Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob6 Ob6
x
Chronic Pain Min No PSE PSE PSE PSE PSE PSE PSE PSE PSE
Ma PTR PTR PTR PTR PTR
Su Su Su Su Su
x B B B B B
Elderl Ob1 Ob1
No pain Min No No No No No No No No
y 2 2
Ma
Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob12 Ob6 Ob6
x
Chronic Pain Min No PSE PSE PSE PSE PSE PSE PSE PSE PSE
Ma PTR PTR PTR PTR PTR PTR PTR PTR
Su Su
x B B B B B B B B
Decompensatio
Min No No PSE PSE PSE PSE PSE PSE PSE PSE
n
Ma PTR PTR PTR PTR PTR PTR PTR PTR
Su Su
x B B B B B B B B
Min Treatment Abb Notes
0 Nothing No
Observation every 36
1 Ob36 - Observation is clinical evaluation and not x-ray everytime
months
- X-rays are usually performed once every two clinical
Observation every 12 evaluations, unless otherwise justified in the opinion of a
2 Ob12
months clinician specialized in conservative treatment of spinal
deformities
Observation every 8
3 Ob8
months
Observation every 6
4 Ob6
months
Observation every 3
5 Ob3
months
- The term "Physiotherapeutic" added to "Physiotherapeutic
Physiotherapeutic Specific Exercises" does not designate an exclusive
6 Specific Exercises PSE professional proposing the exercises, but the general approach
(outpatient) to the patient, that goes beyond the simple execution of
exercises
- According to the actual evidence it is not possible to define
which treatment is more effective than the others between
Night-time Rigid PSE (#6) and PTRB (#10), consequently the progressive
7 NTRB
Bracing (8-12 hours) numbers should be regarded only as a tool to be applied to the
Practical Approach table and not as a classification approved
by SOSORT members
Inpatient
8 SIR
rehabilitation
9 Specific Soft Bracing SSB
Part-Time Rigid The use of a rigid brace always imply the associated use of
10 PTRB
Bracing (12-20 hours) Physiotherapeutic Specific Exercises
Full-time Rigid
11 bracing (20-24 hours) FTRB
or cast
12 Surgery Su
Max
NEVER FORGET
 We do not know why but
the prevalence between 80% of scoliosis curves
male and female are idiopathic.
patients is very different.

in adolescence, the prevalence of

scoliosis curves is 2-3%
In the elderly it is about 60%
Course
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