Scoliosis: Orthopaedic Perspectives

Scott B. Rosenfeld, MD
Division of Pediatric Orthopaedic Surgery
Texas Childrens Hospital
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 Disclosures
I have no disclosures

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 Plan for this talk
Types of Scoliosis
-How imaging is used in
each

What I am looking to
learn from my imaging
studies

How I make treatment

decisions based on
imaging
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 Reality

Vast majority of
scoliosis cases only
require plain
radiographs

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 Types of Scoliosis
Idiopathic (80%)
- Infantile 2mo-3yr
- Juvenile 3yr-10yr
- Adolescent >10yr

Congenital

Neuromuscular
- CP, spina bifida, SCI, DMD

Syndromic Marfans, NF

Thoracogenic

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 Imaging in Scoliosis
Plain radiographs
-Standing PA and lateral
Entire spine on one film
Entire pelvis visible
Risser sign
Tri-radiate cartilage
-Hand for bone age
-Bending radiographs

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 Risser Sign
3 4
2
1
0

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Hand Xray for bone age

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 Imaging in Scoliosis
MRI
- Used to look for intra-spinal
abnormalities
- Things that could get us into
trouble in surgery
Syrinx, tethered cord, Chiari
malformation,
diastametamyelia
- Early onset scoliosis
20%
- Congenital scoliosis
20%

- Left thoracic curves

- Rapid progression

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 Imaging in Scoliosis
CT
-Define bony anatomy
Congenital scoliosis
-Check pedicle screw
position

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 Idiopathic Scoliosis
13 year old female
presents with scoliosis

Postmenarchal

Curve has progressed

over last 2 years

Unhappy with
appearance of her spine
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 63

45

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 Scoliosis Treatment
Depends on how big it is and how
big its going to get

<25 = Observe
63

25-45
- Controversial lots of potential
options
- Immature = consider brace
- Mature = observe

>50 = spinal fusion

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Plan My Surgery

There are 2 curves here

Which one do I fuse?

Need bending films

Structural vs non-structural
curves
- Significance: Structural curves may
need to be included in the fusion
- Criteria for structural
Larger is always structural
Rotated = structural
>25 on bending films =
structural

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13 35

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Choosing fusion levels

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Didnt follow the center sacral line
rule

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 Congenital Scoliosis
6 year old female
presents with spinal
curvature

Stands with significant

lean to the right

Waistline asymmetry

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ge
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 Congenital Scoliosis
Classification
-Failure of formation
Hemivertebra
-Failure of segmentation
Unilateral bar
Block vertebra
-Combination

Need advanced imaging

*Hedequist

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 Congenital Scoliosis
Other things to think
about
-VACTERL syndrome
Vertebral
Anal atresia
Cardiac
Tracheo-Esophageal
fistula
Renal
Limb
-Intraspinal anomalies

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 Congenital Scoliosis
How I think about
treatment
-Is it going to progress?
Highest risk is
hemivertebra with
contralateral bar
Lowest risk is block
vertebra
-I need to know from
advanced imaging what
the anatomy is
*Hedequist

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 Congenital Scoliosis
How I think about
treatment
-Where is it located?
Cervical spine
Thoracic spine
Lumbar spine
-Determines my treatment
approach
Fusion in situ
Hemivertebra excision

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 Congenital Scoliosis
Looks like a right
hemiverebra
between L1 and L2
-I want a 3D CT to
define the anatomy
-MRI to look for intra-
spinal anomalies
-Heart, kidneys
evaluated

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 Congenital Scolosis
Right sided
hemivertebra between
L1 and L2 with no
contralateral bar

Treatment options
-In situ fusion
Limited correction ability
-Hemivertebra excision
with short segment fusion

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 Congenital Scoliosis
Hemivertebra excision
and short segment
fusion

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 Early Onset Scoliosis
Definition Onset prior to
age 5 y.o.

Significance high risk of

progression

T1-S1 growth velocity

-0-5y.o.: 2.2cm/yr
-5-10y.o.: 1cm/yr
-Puberty: 1.8cm/yr

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 Early Onset Scoliosis
High risk of
progression
-Very large curve
magnitude
-Severe cosmetic
deformity
-Significant
pulmonary
dysfunction

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 Early Onset Scoliosis
Pulmonary Dysfunction
-Bronchial tree and alveoli
not fully developed until
8y.o.
-Thoracic volume at
10y.o. only 50% of adult
volume
4 year old with
significant deformity
loses many years of
important pulmonary
development
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 Early Onset Scoliosis
Treatment Options
-Growth Sparing
Serial casting (Risser)
Growing rods
VEPTR
Tethering/Stapling
-Arthrodesis
Not good for
pulmonary
development

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 Early Onset Scoliosis
4 year old presents with
large spinal deformity

No PMH

Neurologically normal

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 Early Onset Scoliosis
What imaging I order
- Standing PA and lateral full
length scoli xrays
What I want to know:
How big is the curve?
Are there congenital
components?

Hemivertebra?
Rib fusion?
Kyphotic or lordotic?

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Early Onset Scoliosis
Advanced imaging
-CT vs MRI
-I need to know:
Is that a congenital
component?
Are there any intra-spinal
anomalies?

Chiari
Syrinx
Tether
Diastametamyelia

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This is where I
really need the
read from the
radiologist

Prevent me from
getting into trouble

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 Early Onset Scoliosis
Decision making
-Young child
-Lots of growth remaining
-Large curve and
progressing
-Normal anatomy
-No intraspinal
abnormality

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 Early Onset Scoliosis
Hybrid expandable construct
- Combination of VEPTR and
growing rods
- Minimal exposure of spine
Cephalad attachments to
ribs
Prevents unwanted spine
fusion
- Expansion every 9 months
- Allow for thoracic growth
- Definitive fusion around 11y.o.

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Thank you

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