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With severe scoliosis patients can develop cor pulmonale. I saw that back in the era before school screenings, when kids would present with 50' curves, it was tragic.
Also, you are correct, most spinal motion is a combination of flexion-extension and rotation.
Well, since I have a captive audience-- heh heh and you are interested in this stuff :P :P :P :P
I hope you don't mind if I share some of this, as I am somewhat interested in this stuff too. :P
Also a little refresher never hurts (me). Anyway, UP, here is some info you may find interesting and probably are familiar with most of it anyway.
I'm taking a break from work and now you have my brain cells engaged, some work break. :eyes:
Here's a little of what I can recall at the moment. :)
Scoliosis is a curvature of the spine in the frontal plane, right to left.
Scoliosis is categorized in the following manner:
Scoliosis
1.) Idiopathic
2.) Congenital
3.) Acquired
a.) fractures
b.) degenerative disc disease
c.) post irradiation
4.) Neuromuscular
a.) Muscular dystrophy comes to mind
b.) Post traumatic, ex: cord injury
Curvatures in the side plane, front to back, are also categorized: These are generally called kyphotic deformaties or kyphosis. That's the kid with slumped posture or the little old lady with an osteoporotic compression fracture that leads to a dowagers hump ( BTW I hate that term, it's unkind, but it is graphic)
Kyphosis:
1.) Postural round back
2.) Scheurmann's disease
3.) Acquired
a.)Compression fractures
b.) disc degeneration
Just to make things interesting, there is another category, called kypho-scoliosis.
In general when we are dealing with kids, teens and young folks, who, as you said, " a teenage boy who slouches," and has a prominent thoracic kyphosis, the differential diagnosis is either postural roundback or Scheurmann's.
A quick test is to have them do a prone push-up, if they raise slowly as requested, you can observe the kyphosis correct, that means it is flexible and most likely postural round back. If it is rigid and does not correct, it is most likely Schuermann's (esp. teen male). Schuermann's can then be diagnosed on plain films, by measuring increased thoracic kyphosis and looking for anterior vertebral wedging >5' in three consecutive vertebrae.
For postural round back, I agree with you, postural cueing and extension exercises at home. If, the pain causes muscle fatigue and over use, then, a short course of PT for upper back strengthening.
When we talk about scoliosis in kids, teens we are most often referring to idiopathic scoliosis.
Now a days with school screening being so efficient, small curves, on average around 12' can be picked up called "schooliosis" LOL, and these require observation only.
Larger curves have guidelines for treatment.
Curves that are flexible and correct with side bending and are below a certain degree may require bracing.
Curves above T10 are treated with a Milwaukee brace, curves with an apex at T10-T12 are generally placed in a lower profile Boston brace (TLSO). That makes a big difference to the kids, as a Milwaukee brace is pretty noticeable.
Curves that progress despite bracing or curves that are above a certain degree on x-ray may require a long spinal fusion.
Most kids fall into the observation group.
Since no one knows what causes idiopathic scoliosis, and I know folks have been looking longer than I can remember, I can't support that exercise causes idiopathic scoliosis to correct nor does it change it's course of progression. However, since exercise in general is good, it can't hurt.
What could hurt is a child the age of ten with a 20' right thoracic and 15' compensatory lumbar curve were advised to undergo chiropractic treatment, or the family was lulled into thinking that curve progression did not require monitoring or treatment, because somehow exercise would change the course of the curve progression.
As far as congenital scoliosis, that is a failure of spine development, either the vertebrae fail to segment or fail to form, thus, growth is unequal by virtue of absent growth plates, those curves tend to be very aggressive and progress rapidly as the child grows.
........
From Duke Univesity Wheeless Textbook of Orthopedics on line:
The Risser classification has to do with closure of the apophyseal cartilage along the ilaic crest and is a kind of measure of skeletal age. The younger the child at presentaton with scoliosis, meaning the longer time left for growth remaining, the more worry that the curve will progress during the grwoth spurt.
Idiopathic Scoliosis:
- Discussion:
- bracing has been the mainstay of non operative treatment of significant curves which have a potential to progress;
- progression is related to size of curve, area of spine involved, & physiologic age of child;
- size of curve:
- larger curves progress to > deg than smaller curves (many curves less than 30 degrees don't progress);
- thoracic and double primary curves progress more than single lumbar or thoracolumbar curves.
- physiologic age (based on menarche & risser status);
- Risser stage 0-1: curves between 20-29 deg have > 65% risk of progression;
- Risser grade 2-4: curves between 20-29 deg have > 20% risk of progression;
- the major controversy surrounding bracing is whether or not it can influence the natural history of scoliosis;
- in the review article by RA Dickson and SL Weinstein (JBJS-B March 1999), the authors make several points;
- the authors note that the Cobb angle remains the main determinate of curve severity eventhough this is a two demensional
measurement of a three demensional deformity (it may not be the most optimal measurement of curve severity and correction);
- use of a brace in flexible curves may actually reduce the Cobb angle by flattening the lumbar lordosis which negatively affects
the saggital component of the scoliotic curve;
- hence ensure that use of a brace is not actually worsening thoracic lordosis (which is often the predominant aspect of scoliosis;
- authors note that there is some evidence that bracing is ineffective in treating scoliotic curves;
- reference:
- A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.
CJ Goldberg et al. Spine. Vol 18. 1993. p 902-908.
- Brace compliance in adolescent idiopathic scoliosis. GR Houghston et al. JBJS Vol 69-B. 1987. p 852.
- Use of the Milwaukee brace for progressive idiopathic scoliosis. KJ Noonan et al. JBJS Vol 78-A. 1996. 557-567.
--------------------------------------------------------------------------------
- Guidelines for Brace Use:
- less than 30 deg:
- curves < 20 deg are treated by observation alone;
- patients presenting w/ idiopathic spinal curves < 30 deg should be observed for progression ( > 5 deg change in 6 mo) before instituting bracing.
- ie, curves between 20 and 29 deg that show progression need to be treated w/ orthosis;
- greater than 30 deg;
- curves between 30 and 40 deg are treated w/ orthosis on first visit to office if they are less than Risser 3;
- hence, skeletally immature patients w/ significant curves (greater than 30 deg) require bracing even if there is no evidence of progression;
- greater than 45 deg;
- although some flexible curves between 40 and 45 deg can be treated successfully, bracing is not used for most curves > 45 deg;
--------------------------------------------------------------------------------
- Vital Capacity: (see cardiopulmonary function in scoliosis)
- application of brace results in a significant reduction in vital capacity (14%), functional residual capacity (22%), & total lung capacity (12%);
- bracing will reduce lung function by 10 to 15%;
--------------------------------------------------------------------------------
- Special Considerations:
- infantile scoliosis:
- bracing is the primary treatment for pts with infantile and juvenile idiopathic scoliosis;
- types of braces:
- curves w/ apices lower than T-8 or lower may be treated w/ underarm braces,
such as Wilmington brace (custom made) or Boston brace (prefabricated)
- these curves cannot be except to treat higher curves;
- high thoracic curves may require the Milwaukee Brace;
- how many hours per day is necessary?
- as noted by Rowe et al, probability of a successfull result was directly related to number of hours braces was worn per day;
- 23 hours was more effective than 16 hours which was more effective than 8 hrs;
................
This may be of interest to you:
The Journal of Bone and Joint Surgery 82:1157 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Current Concepts Review
Etiology of Idiopathic Scoliosis: Current Trends in Research*
Thomas G. Lowe, M.D., Michael Edgar, M.Chir., F.R.C.S., Joseph Y. Margulies, M.D., Ph.D.§, Nancy H. Miller, M.D.#, V. James Raso, M.A.Sc.**, Kent A. Reinker, M.D. and Charles-Hilaire Rivard, M.D.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Woodridge Orthopaedic and Spine Center, 3550 Lutheran Parkway West, Suite 201, Wheat Ridge, Colorado 80033.
Orthopaedic Department, Middlesex Hospital and University College London, 149 Harley Street, London W1N 2DE, United Kingdom.
§Department of Orthopedic Surgery, Montefiore Medical Center, 111 East 210th Street, Bronx, New York 10467.
#Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Suite 5254, Baltimore, Maryland 21287.
**Orthopaedic Engineering Group, Glenrose Rehabilitation Hospital, 1023 111th Avenue, Edmonton, Alberta T5G 0B7, Canada.
Department of Orthopedic Surgery, Shriners Hospital for Children, 13 Punahou Street, Honolulu, Hawaii 96826.
Centre de Recherche Pediatrique, Hôpital Sainte-Justine, 3175, Cote Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada.
Introduction
Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity.
The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms.
Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself.
Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine.
The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.
Idiopathic scoliosis is a pathological entity of unknown etiology. Although the entity was first described by Hippocrates, the term idiopathic scoliosis was probably introduced in the middle of the nineteenth century by Bauer39; it was used by Nathan in 190967, defined by Whitman in 192293, included by Cobb in his classification19, and popularized by the Scoliosis Research Society40. Although most physicians who treat spinal deformities understand the term idiopathic scoliosis, the important questions concerning its etiology remain unanswered.
The objectives of this paper are to provide an update on a number of aspects of the etiology of idiopathic scoliosis, to present an inventory of current investigational work, and to suggest directions for future research. The identification of etiological factors will depend on continued research in each of the areas discussed in this review. Further understanding of this disorder will enable the clinician to better predict prognosis and to aid in the development of more effective treatment modalities. This work represents an effort on the part of the Scoliosis Research Society Etiology Committee to promote an awareness of the research in this field.
.....................
OK--back to work for this dawggy :hi:
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