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Essentials of Skeletal Radiology3rd Edition

© 2005 Lippincott Williams & Wilkins←↑→

4Scoliosis

Lindsay J. Rowe

Terry R. YochumChad J. Maola

Norman W. Kettner

GENERAL CONSIDERATIONSThe term scoliosis is usually credited to Hippocrates. (1) Its derivation is from the Greek word skolios, meaning

“twisted” or “crooked.” In general, any lateral curvature of the spine > 10° in the coronal plane is called a scoliosis,

though many use the term to describe any lateral spinal deviation. Curves of 5-10° have been found in up to 15% ofschool pupils. (2) The incidence of scolioses > 10° is estimated between 2% and 4% in the general population. (3)

The common right (dextro) thoracic curve, measuring < 10°, is generally considered physiologic and is thought to

accommodate the size and position of the heart, lung, and aorta or to be related to handedness. (4) Spontaneousresolution or improvement of curves < 10° can be observed in 3-20% of individuals, mostly boys. (5,6)

A review of the literature on this subject reveals a voluminous amount of information and sophisticated research, but

there is still little insight into the origin of most scoliotic deformities. The largest category of scoliosis classificationcontinues to be idiopathic, underscoring the need for continuing etiological research. There is a similar need in the

area of treatment, in which the search for effective, conservative means to prevent or correct significant curves

continues. This chapter is not intended to be an encyclopedic resource on the topic of scoliosis but rather anoverview of the fundamental concepts and principles related to the application of diagnostic imaging in the clinical

assessment of scoliosis.

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GlossaryA standard nomenclature is essential for accurate communication and description of scoliosis. (7,8) Numerous

terms are employed in the description of scoliotic deviations, vertebral abnormalities, and related findings. These

have been standardized by the Terminology Committee of the Scoliosis Research Society. (8)

adolescent scoliosisSpinal curvature presenting at or about the onset of puberty and before maturity (10-25 years).

adult scoliosis

Spinal curvature existing after skeletal maturity.angle of inclination

With the trunk flexed 90° at the hips (Adam’s position), the angle formed between horizontal and a plane across the

posterior rib cage at the greatest prominence of a rib hump.apical vertebra

The most rotated vertebra in a curve; the most deviated vertebra from the vertical axis of the patient.

body alignment, balance, compensation

(a) The alignment of the midpoint of the occiput over the sacrum in the sagittal plane line. (b) In radiology, when thesum of the angular deviations of the spine in one direction is equal to that in the opposite direction.

cervical curveSpinal curvature that has its apex from C1 to C6.

cervicothoracic curve

Spinal curvature that has its apex at C7 or T1.compensatory curve

A curve above or below the primary curve, functioning as an adaptation to the primary curve and maintaining normal

body alignment. It may be structural.congenital scoliosis

Scoliosis as a result of congenitally anomalous vertebral development.

curve measurementTwo methods are commonly employed.

Cobb’s method. Select the upper and lower end vertebrae and draw lines to represent their transverse axes(usually the superior and inferior endplates, respectively). From these lines, project intersecting perpendicular







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lines. The vertical (not horizontal) angle formed at this intersection represents curve magnitude. If the vertebralendplates are

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poorly visualized, a line through the bottom or top of the pedicles may be used.Risser-Ferguson method. The angle of a curve is formed by the intersection of two lines drawn from the center

of the superior and inferior end vertebral bodies to the center of the apical vertebral body; less commonly used.

dextroscoliosis

The convexity of the scoliosis is directed to the right side of the body.double major scoliosis

A scoliosis with two structural curves occurring in different spinal areas.

double primary scoliosisA scoliosis with two curves occurring in one spinal area.

double thoracic curve (scoliosis)

A scoliosis with a structural upper thoracic curve; a larger, more deforming lower thoracic; and a relatively non-

structural lumbar curve.end vertebra

Segments used to measure curve magnitude. The superior end vertebra is the segment in which the superior

endplate is maximally tilted toward the concavity of the curve. The inferior end vertebra is the segment in which theinferior endplate is maximally tilted toward the concavity of the curve.

full curve

A curve in which the only horizontal vertebra is at the apex.functional curve

A compensatory curve that is incomplete because it returns to the erect. Its only horizontal vertebra is its caudad or

cephalad one.genetic scoliosis

A structural spinal curvature inherited according to a genetic pattern.

gibbusA sharply angular kyphosis occurring over one to three vertebral segments.














hysterical scoliosisA non-structural deformity of the spine that develops as a manifestation of a psychiatric conversion reaction.

idiopathic scoliosis

A structural spinal curvature for which no cause is established; accounts for up to 80% of curvatures.

iliac epiphysis (apophysis)The secondary ossification center along the wing of the ilium.

iliac epiphysis sign (apophysis sign, Risser’s sign)

An assessment of progression of the iliac crest apophysis as seen on the anteroposterior (AP) radiograph. GradedI-IV, it indicates skeletal maturity. When the progression of ossification in the iliac epiphysis (apophysis) reaches its

ultimate medial migration, vertebral growth may be complete.

infantile scoliosisSpinal curvature developing during the first 3 years of life.

juvenile scoliosis

Spinal curvature developing between skeletal age 3 years and the onset of puberty (3-10 years).

kyphoscoliosisLateral curvature of the spine associated with an increased concavity anteriorly in excess of the accepted regional

norm. In the thoracic region, 20-40° of kyphosis is considered normal.kyphosis

A change in the alignment of a segment of the spine in the sagittal plane that increases the posterior convex

angulation.levoscoliosis

The convexity of the scoliosis is directed to the left side of the body.

lordoscoliosisLateral curvature of the spine associated with a decreased anterior concavity, outside of normal range for that

region. In a thoracic spine, in which an anterior concavity is normally present, curves < 20° would constitute

lordoscoliosis.lumbar curve

Spinal curvature that has its apex from L2 to L4.

lumbosacral curveSpinal curvature that has its apex at L5 or below.










major curve

Designates the larger(est) curve(s), usually structural.

minor curveTerm used to refer to the smaller(est) curve(s).

myogenic scoliosis

Spinal curvature caused by disease or anomalies of the musculature.neurogenic scoliosis

Spinal curvature caused by disease or anomalies of the nervous system.

non-structural scoliosis (functional)A curve that has no structural component and that corrects or overcorrects on recumbent side-bending radiographs.

osteogenic scoliosis

Spinal curvature owing to abnormality of the vertebral elements and /or adjacent ribs, acquired or congenital.pelvic unleveling

Deviation of the pelvis from the horizontal in the frontal plane. Fixed pelvic unleveling can be attributable to

contractures either above or below the pelvis.primary curve

The first or earliest of several curves to appear, if identifiable.

rib humpThe prominence of the ribs on the convexity of a spinal curvature, usually the result of vertebral rotation, best

exhibited on forward bending.

rotoscoliosisScoliosis with rotated vertebral bodies.

skeletal age (bone age)The age obtained by comparing an AP radiograph of the left hand and wrist with the standards from the Greulich andPyle Atlas.

structural curve

A segment of the spine with a fixed lateral curvature. Radiographically, it is identified in supine lateral side-bendingfilms by the failure to correct. There may be multiple structural curves.

thoracic curve









Scoliosis in which the apex of the curvature is between T2 and T11.thoracogenic scoliosis

Spinal curvature attributable to disease or operative trauma in or on the thoracic cage.

thoracolumbar curve

Spinal curvature that has its apex at T12 or L1.CLASSIFICATION

Curves are classified in three ways, based on cause, location, and direction. The causal classification for scoliosis

is the most accepted method of categorizing lateral spinal column deviations. (1) This method of classificationincludes two major descriptions of scoliosis, identifying them as either structural or non-structural. Within these two

major divisions, the specific origin of the scoliosis is then identified. (Table 4-1) The location classification is based

on the region of the spine in which the apex vertebra is located and describes the curvature. (Fig. 4-1; Table 4-2)Classification based on direction describes the plane into which the concavity of the curve projects, for example,

dextroscoliosis ( patient’s right), levoscoliosis ( patient’s left), lordoscoliosis ( patient’s anterior), and kyphoscoliosis

(patient’s posterior). Throughout this chapter we use the causal classification of scoliosis.

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Table 4-1 Causal Classification of Scoliosis

Structural scoliosis

I.Idiopathic

A.Infantile

1. Resolving

2. Progressive





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B.Juvenile (3-10 years)

C.Adolescent (> 10 years)

II.Neuromuscular

A.Neuropathic

1. Upper motor neuron

a. Cerebral palsy

b. Spinocerebellar degeneration

(1) Friedreich’s disease

(2) Charcot-Marie-Tooth disease

(3) Roussy-Levy disease

c. Syringomyelia










d. Spinal cord tumor

e. Spinal cord trauma

f. Other

2. Lower motor neuron

a. Poliomyelitis

b. Other viral myelitides

c. Traumatic

d. Spinal muscular atrophy

(1) Werdnig-Hoffmann

(2) Kugelberg-Welander

e. Myelomeningocele (paralytic)








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3. Dysautonomia (Riley-Day)

4. Other

B.Myopathic

1. Arthrogryposis

2. Muscular dystrophy

a. Duchenne’s (pseudo-hypertrophic)

b. Limb-girdle

c. Facioscapulohumeral

3. Fiber-type disproportion

4. Congenital hypotonia

5. Myotonia dystrophica






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6. Other

III.Congenital

A.Failure of formation

1. Wedged vertebra

2. Hemivertebra

B.Failure of segmentation

1. Unilateral (unsegmented bar)

2. Bilateral

C.Mixed

IV.Neurofibromatosis

V.Mesenchymal disorders






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A.Marfan’s

B.Ehlers-Danlos

C.Other

VI.Rheumatoid disease

VII.Trauma

A.Fracture

B.Surgical

1. Postlaminectomy

2. Post-thoracoplasty

C.Irradiation

VIII.Extraspinal contractures






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A.Postempyema

B.Postburn

IX.Osteochondrodystrophies

A.Diastrophic dwarfism

B.Mucopolysaccharidoses (e.g., Morquio’s syndrome)

C.Spondyloepiphyseal dysplasia

D.Multiple epiphyseal dysplasia

E.Other

X.Bone infection

A.Acute

B.Chronic





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XI.Metabolic disorders

A.Rickets

B.Osteogenesis imperfecta

C.Homocystinuria

D.Other

XII.Related to lumbosacral joint

A.Spondylolysis and spondylolisthesis

B.Congenital anomalies of the lumbosacral region

XIII.Tumors

A.Vertebral column

1. Osteoid osteoma

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2. Histiocytosis X

3. Other

B.Spinal (see II. Neuromuscular)

Non-structural scoliosis

I.Postural

II.Hysterical

III.Nerve root irritation

A.Herniation of the nucleus pulposus

B.Tumors

IV.Inflammatory (e.g., appendicitis)

V.Related to leg length discrepancy




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Thoracolumbar T12-L1

Lumbar L2-L4

Lumbosacral L5-S1

Structural

A structural scoliosis is a lateral curvature that is rigid and fails to correct on recumbent or lateral-bendingradiographic studies. Many disorders cause a structural scoliosis, including idiopathic, congenital segmentation

anomalies, neuromuscular, neurofibromatosis, and others. (Table 4-1)

IdiopathicIdiopathic scoliosis is the most common form of lateral spinal deviation, accounting for up to 80% of scoliosis. (2)

The cause is unknown, although many factors have been implicated, including connective tissue disease, diet,

enzymes, muscular imbalance, vestibular dysfunction, and inheritance. (3,4) Of all possible causes, an inheritedgenetic defect appears to play a significant role; up to 30% of patients have another family member with significantscoliosis. (5,6,7) A positive family history does not translate into worse curves or progressive curves. (7) In idiopathic

scoliosis, < 2% of the thoracic curves occur to the left, but when present they are more common in females than in

males and have a higher incidence of underlying pathology. (8)The onset for idiopathic curves distinctively occurs during growth periods, which allows for further classification

based on age. This age-based classification categorizes the curves as infantile, juvenile, or adolescent idiopathic

scolioses.Infantile Idiopathic Scoliosis.

The infantile form occurs between birth and 3 years of age. The majority will disappear (resolving infantile idiopathic

scoliosis), but some will progress (progressive infantile idiopathic scoliosis). (9) The progressive form is rare in theUnited States, is slightly more common in males, and is usually a left convex thoracic curve.

Juvenile Idiopathic Scoliosis.

The onset of juvenile idiopathic scoliosis is between 3 and 10 years of age, with an average age of 7 years. There isfemale gender predominance of 4 to 1. (10) Thoracic curves are the most common type. As many as 30% will

eventually require corrective surgery

















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eventually require corrective surgery.Adolescent Idiopathic Scoliosis.

The adolescent form is the most common type of idiopathic scoliosis. Females are predominantly affected, in a ratio

of 9 to 1, and the most frequent curve is the right thoracic convexity. (11) The curvature develops in the period

between the age of 10 and skeletal maturity, and the curvature is often discovered during the screening ofschoolchildren with the Adam’s test. If during the Adam’s test forward flexion reveals a rib hump, a structural

scoliosis with rotation should be suspected. (Fig. 4-2) The critical time period for progression,

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which may be rapid, is between the ages of 12 and 16 years. (Fig. 4-3) Once spinal growth has ceased, as

indicated by fusion of the iliac apophysis, further rapid progression is unlikely, although slow progression ofidiopathic curves throughout adulthood is a recognized complication.









physical observation of a persistent rib hump on forward flexion (Adam’s position) characteristic of a structural




physical observation of a persistent rib hump on forward flexion (Adam s position) characteristic of a structuralscoliosis.

Figure 4-3 IDIOPATHIC SCOLIOSIS. A. AP Lumbar Spine. The abnormality in this 25-year-old female was first

detected when she was 12 years of age. Despite bracing, her scoliosis progressed and then remained unchangedas shown here. B. AP Thoracic Spine. Observe the right convex midthoracic scoliosis in this 23-year-old female; it

was clinically silent and fortuitously discovered during a chest radiographic examination COMMENT: Many







was clinically silent and fortuitously discovered during a chest radiographic examination. COMMENT: Many

idiopathic scolioses remain asymptomatic and may be found as an incidental finding in adulthood. Cosmetic

deformity may be slight despite even relatively large magnitude scoliotic curvatures.The natural history of scoliosis has not significantly changed over the years. (12) Later in adult life superimposed

degenerative changes may allow the curvature to increase on an average of 15° (13) and occasionally may create

nerve entrapment syndromes. (14) Generally, curves of greater magnitude at skeletal maturity show greaterprogression through adulthood. In severe curves, iliocostal pain may occur secondary to rib impingement onto the

iliac crest. (Fig. 4-4)Other findings in idiopathic scoliosis are the development of lateral wedge deformities of the vertebral bodies withinthe apex of the curve. These wedge deformities persist into adult life and are the result of excessive compressive

forces that impair the growth at the discovertebral junction on the concave side of the curvature (Hueter-Volkmann

principle). (Fig. 4-5) Three other curves that are frequently present are a right thoracolumbar, a left lumbar, and acombined form of left lumbar and right thoracic. (2,15) The normal psoas shadow on frontal radiographs is often not

visualized on the concave side of a lumbar scoliosis. (16)

There is a 10 times greater incidence of congenital heart disease than in the general population when the idiopathiccurve is > 20°. (17) The lumbar lordosis, thoracic kyphosis, and cervical lordosis are often reduced, and an

increased incidence of co-existing pes cavus has been noted. (18)

















Figure 4-4 ADVENTITIOUS BURSA, ILIOCOSTAL IMPINGEMENT. CT, Axial Subcostal Region. Observe the fluiddensity soft tissue mass between the ribs and the iliac crest, where impingement was occurring from an adventitious

bursa (arrows). COMMENT: This 45-year-old female patient had suffered severe thoracolumbar scoliosis of at least60° since adolescence and ambulated with a walking aid. She then complained of anterolateral pain near the tips of

the eleventh and twelfth ribs. After the CT study a single injection of corticosteroid under ultrasound guidance

relieved all pain, and a follow-up CT 4 weeks later confirmed its resolution.P.410













Figure 4-5 HUETER-VOLKMANN PRINCIPLE. A. AP View. Excessive compressive axial loading at the







discovertebral junction (arrowheads) owing to scoliosis during the period of bone growth may produce permanent

wedge-shaped vertebral bodies. B. AP Thoracic Spine. The four vertebral bodies at the apices of the curves are

notably wedged. Also observe the pedicle migration of these segments, signifying vertebral rotation. (Courtesy of

Leo C. Wunsch Sr, DC, DACBR, Denver, Colorado.)Congenital

Congenital scoliosis is distinguished by associated anomalies of the vertebrae or ribs. The most frequently

observed anomalies are hemivertebrae, block vertebrae, spina bifida, bridging vertebral bars, joint deformities,fusion of ribs, and other rib malformations. (19) (Fig. 4-6) The scoliosis is typically a short C-shaped curve and may

be rapidly progressive during growth spurts. Occasionally, anterior vertebral body defects may cause superimposed

kyphosis (kyphoscoliosis). (20) There is a frequent association of genitourinary system anomalies with congenitalscoliosis. (21)

Neuromuscular

A large spectrum of neuropathic and myopathic disorders may produce a progressive spinal deformity. (Table 4-1)Neuropathic scoliosis is distinctively a long C-shaped curve, frequently extending from the sacrum to the lower

cervical region. The most common neuropathy associated with scoliosis is poliomyelitis. (22) The convex side isoriented toward the unaffected muscle group. Intersegmental rotation may be severe in these curves, and rapidprogression in the curvature angle frequently occurs between the ages of 12 and 16 years. Cerebral palsy produces

the same type of long C-shaped curve. Other neurologic disorders associated with scoliosis include syringomyelia,

spinal cord tumor, trauma, and dysautonomia. A scoliosis of 15° or more occurring before the age of 11 should beviewed with a high index of suspicion for underlying intraspinal pathology. (23) (Fig. 4-7) Left-sided thoracic curves

similarly have a higher incidence of intraspinal pathology, including tumors of the spinal cord or vertebrae,

syringomyelia, and Arnold-Chiari malformations, all of which are best evaluated with MRI. (24,25)Myopathic scoliosis is usually of the long C-shaped curve configuration. The most frequent cause is muscular

dystrophy of Duchenne. An increasing lordosis usually precedes the onset of the scoliotic deformity. (26) The

scoliosis that forms is often rapidly progressive and severe, requiring fusion and rod instrumentation. Once thepatient has been confined to a wheelchair, the formation of a scoliosis is almost inevitable. (27)

Neurofibromatosis

Neurofibromatosis is an inherited congenital disorder of neuroectodermal and mesodermal origin tissues. The firstdescription of the relationship between the formation of nerve and skin tumors was given by von Recklinghausen in

1882. (28) Scoliosis was first associated with neurofibromatosis in 1921 by Weiss. (29) The classic triad of




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diagnostic findings is (a) multiple, soft, elevated cutaneous tumors (fibroma molluscum); (b) cutaneous

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pigmentation (café-au-lait spots); and (c) neurofibromas of peripheral nerves. In addition, various skeletal lesions,

including erosions, intraosseous cystic defects, deformity, pseudo-arthrosis, growth aberrations, and cranialabnormalities, may be present in up to 50% of these patients. (30)








Figure 4-6 CONGENITAL SCOLIOSIS. A. Hemivertebra AP Lumbar Spine. Observe the two pedicles at the apex ofthis thoracolumbar scoliosis, caused by a fused hemivertebra (arrows). B. Lumbar Hemivertebra. An unfused

hemivertebra that has precipitated a structural scoliosis (arrow) is demonstrated. C. Hemivertebra with Disc

Degeneration, AP Lumbar Spine. Note the fused hemivertebra at the apex of this midlumbar scoliosis (arrows).Observe the severe disc degeneration of the lower lumbar segments with exuberant osteophytes, sclerosis, and loss

of disc space, which is maximal on the concave side of the scoliosis. D. Synostosis, AP Ribs. Observe the

thoracolumbar scoliosis as a result of a congenital localized lack of separation at the eleventh and twelfth ribs(arrow). (Panel A courtesy of Russell Banks BAppSc (Chiro), Melbourne, Australia.)

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Figure 4-7 LEFT THORACIC SCOLIOSIS. AP Thoracolumbar Spine. Observe the long segment, C-shaped

scoliosis convex to the left as evident by the relative positions of the heart and gastric air bubble. COMMENT: Leftthoracic curves in patients under the age of 11 years may be a marker for underlying spinal canal tumors,

syringomyelia, posterior fossa brain tumors, and Arnold-Chiari malformations. MRI of the entire spinal cord, including

the posterior fossa, should be performed on the basis of this finding. (Courtesy of Anne P. Odenweller, DC, Baton

Rouge, Louisiana.)Scoliosis is the most common bony abnormality in neurofibromatosis patients and is present in 10-50% of cases.

(30,31,32) Varying degrees of scoliosis occur, from mild to severely deforming angulations. (Figs. 4-8 and 4-9) Themost conspicuous features, when present, consist of a short, angular deformity with dysplasia of the vertebral

bodies. Notably, the scoliosis frequently progresses and requires surgical fusion for stabilization. Kyphosis is the

most common superimposed deformity. Additional findings that suggest neurofibromatosis-induced scoliosis areenlarged foramina, posterior and lateral vertebral body scalloping, deformed ribs (twisted ribbons), and an adjacent

smooth paraspinal soft tissue mass owing to either a neurofibroma or a protruding lateral meningocele.

Miscellaneous CausesInfection.

Infectious processes, such as tuberculosis, may precipitate spinal deformity as a result of collapse and bony

destruction. (Fig. 4-10) The most distinctive deformity is a sharp, angular kyphosis (gibbus), although varyingdegrees of scoliosis may also occur.

Radiation.

Irradiation of the growing spine may produce vertebral abnormalities in up to 75% of patients. (33) These changes

consist of growth arrest lines, endplate irregularities, altered vertebral shape, and scoliosis. The most commonlyirradiated childhood disorders are Wilms’ tumor in the kidney and neuroblastoma in the adrenal gland. The focal

point of the irradiation is the organ of involvement; however, the adjacent spine and iliac bone are frequentlyoverlapped and affected by the treatment. This overlap produces the classic tandem findings of a small iliac wing,

small vertebral bodies, and a lumbar scoliosis with a convexity away from the irradiated side. (Fig. 4-11) Two types

of lumbar spine deformity can occur: a mobile scoliosis and a fixed rotary scoliosis caused by unilateral shortenedlaminae and pedicles. (34) In both types of curves, the convexity is away from the side of irradiation.

Trauma.Injuries to the spine that produce fracture or dislocation may also induce a lateral spinal curvature which may be

















Injuries to the spine that produce fracture or dislocation may also induce a lateral spinal curvature, which may be

permanent. (Fig. 4-12) Most spinal injuries produce curves that are concave to the side of injury; however, transverse

process fractures are unique in that they commonly produce curves that are convex to the side of fracture. Although

other spinal injuries are compressive in nature, transverse process fractures are avulsions created by the attachedmusculature. (35)

Spondylolisthesis.

Scoliosis found in association with lumbar spondylolisthesis is common, found in almost 25% of cases. The cause isoften difficult to determine, but in 30% of

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cases, the scoliosis may be the result of greater slippage of the spondylolytic vertebra on one side (olisthetic

scoliosis). (36) (Fig. 4-13) A more common cause of scoliosis, seen in at least 40% of spondylolisthesis cases, is

muscle spasm caused by pain. (37) Scoliosis in asymptomatic spondylolisthesis occurs in 6% of cases. (37)













Figure 4-8 NEUROFIBROMATOSIS. A. AP Lower Cervical Spine. Observe the mild cervicothoracic scoliosis; themost dramatic changes are foraminal expansion (arrowheads) and lateral vertebral scalloping (arrows). B. Oblique

Cervical Spine. Note that the foramina are greatly expanded from marked dural ectasia (arrowheads); note also the

posterior scalloping of the vertebral bodies (arrows). C. AP Upper Thoracic Spine. Observe the upper thoraciccurvature, lateral body scalloping (arrows), and the paraspinal mass (arrowhead) of an associated meningocele. D.

AP Lumbar Spine. Observe the bizarre distortion of the lumbar bodies, posterior arches, and intervertebral foramina

accompanying the scoliosis. COMMENT: Scoliosis is a common finding in neurofibromatosis and is oftenassociated with kyphosis. (Panels A and B courtesy of William E. Litterer, DC, DACBR, Fellow, ACCR, Elizabeth,

New Jersey; panel C courtesy of Clayton F. Thomsen, DC, Sydney, Australia; panel D courtesy of Lawrence A.Cooperstein MD Pittsburgh Pennsylvania )











Cooperstein, MD, Pittsburgh, Pennsylvania.)

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Figure 4-9 NEUROFIBROMATOSIS. AP Thoracolumbar Spine. Observe the marked, right, short-segment thoracic

scoliosis and the presence of the soft tissue opacity over the left eleventh rib, which is the silhouette of a cutaneousfibroma molluscum (arrow).







Figure 4-10 STRUCTURAL SCOLIOSIS, TUBERCULOUS SPONDYLITIS (POTT’S DISEASE). AP Thoracolumbar

Spine. Note the angular scoliosis focused at T9-T11. There has been vertebral collapse with the down sloping of the

ribs owing to a gibbus deformity. Flocculent soft tissue calcification within the accompanying cold abscess ispresent in the paraspinal soft tissues (arrows).













Figure 4-11 RADIATION-INDUCED SCOLIOSIS, WILMS’ TUMOR. Intravenous Pyelography, AP Lumbar Spine.Observe the right convex upper lumbar rotary scoliosis, with the apex at L1. The pedicle and spinous process

positions confirm the rotational element present. Note the hypoplasia of the pedicle and lateral half of the vertebral

bodies of L1-L4 (arrows). COMMENT: The underdevelopment is radiation-induced stunted growth. This patient hadradiation treatment after a nephrectomy, 4 years before this study.

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Figure 4-12 TRAUMATIC SCOLIOSIS. A. AP Thoracolumbar Spine. Observe the comminuted “burst” fracture at

T12, with loss of vertebral body height, lateral wedging, and widening of the interpediculate space. An angularscoliosis is present above this fractured segment. B. AP Lumbar Spine. Note that the complete facet luxation at the

L2-L3 interspace (arrows) has produced an angular scoliosis. Observe the superior endplate compression fracture

of L3 (arrowhead).Degenerative Joint Disease.







Advanced discopathy and facet arthrosis may result in a scoliotic deviation, especially when the changes are

extensive unilaterally. (Fig. 4-14) Such curvatures are designated degenerative scoliosis.

Other Disorders.Many other conditions precipitate a structural scoliosis. Bone tumors, especially osteoid osteoma, produce a rotary

scoliosis. This tumor is usually located in the pedicle-facet region of the apical vertebra on the concave side of the

curve. (Fig. 4-15) Radiographically, the nidus of an osteoid osteoma is often occult, and a sclerotic pedicle is theonly identifiable sign. A nuclear bone scan may be necessary for the definitive detection of osteoid osteomas.

Connective tissue diseases, like Ehlers-Danlos and Marfan’s syndromes, often produce rapidly progressive double

thoracolumbar curves with a marked rotational element. (Fig. 4-16)Non-Structural

Curvatures that have no structural alteration and that correct on recumbent lateral-bending radiographic studies are

classified as non-structural and have a number of possible causes. (Table 4-1)Leg Length Inequality

Differences in leg length (short leg syndrome) are common in both asymptomatic and low back pain individuals. Leglength inequality (LLI) in asymptomatic individuals has been documented in up to 43% of persons, whereas in those

with back pain incidences as high as 75% have been recorded. (38,39) Many leg length differences have no known

cause, though previous fractures, epiphyseal disorders, juvenile arthritis, and osteoarthritis can all precipitate growth

defects.Imaging methods for the diagnosis of LLI are numerous, each with its advantages and disadvantages. (40) Erect

radiography (orthoradiography) of the pelvis and lumbar spine is commonly employed to analyze the femoral head

and iliac crest height. This requires standardized foot, pelvic, and tube positioning. (41) Slit collimation plain film

radiography involves placing a ruler alongside the legs. Tightly collimated bilateral radiographs are takensequentially on a single film of the hips, knees, and ankles. CT scanography involves an AP scanogram performed

by CT from the pelvis to the ankles and then measured digitally at standard points.A characteristic constellation of radiographic findings are found on erect radiography of the lumbar spine and pelvis

in the presence of a short leg. (38,42,43) (Figs. 4-17 and 4-18; Table 4-3)

Pelvic and sacral unleveling. On the side of the short leg the iliac crest and sacral base is low.

Convex rotary lumbar scoliosis. The lumbar spine compensatory scoliosis is convex to the side of the short legand exhibits varying degrees of physiological-coupled intersegmental rotation, with the spinous processes





















usually displaced toward the concavity of the curve. The apex of the curve is typically at L1-L2 and the superior

end vertebra is in the lower thoracic spine (T9-T11).

Compensatory contralateral thoracic scoliosis. A smaller thoracic curve is often present, convex to the long legside. There is usually no intersegmental rotation present.

Vertebral degenerative disc disease. Osteoarthritic changes are more severe on the concave side of the

curve, with spondylophytes, sclerosis, and loss of disc height.Deeper nuclear impressions. On the convex side of the scoliosis, the depth of nuclear endplate impressions

(notochordal remnants) are of greater depth and are found toward the midline as a marker of nucleus pulposus

displacement. (43,44) These changes are most prominent at the apical vertebra, especially the inferiorendplate.

Vertebral body wedging. Decreased height, especially of the L5 vertebra, is occasionally seen on the long leg

side.Lumbosacral facet angles. On oblique studies the angle of the lumbosacral posterior joint is more horizontal on

the short leg side and more vertical on the long leg side. (45)Degenerative joint disease of the sacroiliac and hip joints. On the short leg side increased chronic weight-bearing stresses may precipitate arthritic changes. (46)

Femoral neck changes. On the short leg side a frequent finding is compensatory thickening of the primary

compressive trabeculae in the femoral neck and a thickened medial cortex, often with a layer of periosteal newbone evident (buttressing of the femoral neck).

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Figure 4-13 OLISTHETIC SCOLIOSIS. A. AP Lumbar Spine. Observe the mild right rotary lumbar scoliosis. A spina

bifid lt i t t L5 ( ) hi h i i hi h i ti ith d l l i B L t l L b l







bifida occulta is present at L5 (arrow), which is seen in high association with spondylolysis. B. Lateral Lumbosacral

Spine. Note the grade 1 spondylolisthesis with anterior slip at L5. C and D. Oblique Lumbar Spine. Analysis of facet

alignment from superior to inferior reveals that on the right side, correlating with the scoliosis concavity, the L5-S1facet joint is well posterior to L4-L5 compared with the left side (stepladder sign) (arrows). COMMENT: Scoliosis up

to 10° is common with spondylolisthesis and appears to be the result of the serial appearance of bilateral pars

defects rather than being simultaneously bilateral. Essentially this leads to forward slip on one side, inducing thescoliosis.

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Figure 4-14 DEGENERATIVE DISC AND APOPHYSEAL JOINT DISEASE PRODUCING SCOLIOSIS. AP LumbarSpine. Severe discopathic alterations at the second, third, and fourth lumbar discs with associated facet arthrosis

have produced lateral listhesis and lateral flexion at these levels. COMMENT: These degenerative changes have

resulted in a mild structural scoliosis and predispose the patient to spinal stenosis.







Figure 4-15 SCOLIOSIS CAUSED BY OSTEOID OSTEOMA. AP Lumbar Spine. Observe the localized scleroticfocus overlying the L3 pedicle on the concave side and at the apex of the rotary scoliosis (arrows). COMMENT:

These benign tumors are painful and characteristically induce a rotatory scoliosis; the lesion is usually located on the







These benign tumors are painful and characteristically induce a rotatory scoliosis; the lesion is usually located on the

concave side. The differential diagnosis of a unilateral sclerotic lumbar pedicle includes contralateral pedicle

agenesis and pars defect. (Courtesy of Jack Edeiken, MD, Houston, Texas.)








Figure 4-16 SCOLIOSIS ASSOCIATED WITH MARFAN’S SYNDROME. AP Thoracolumbar Spine. Observe thesevere double lumbar and thoracic curve with rib deformity and marked lumbar rotation. COMMENT: Rapidly

progressive scoliosis is common in connective tissue diseases such as Marfan’s and Ehlers-Danlos syndromes.







Figure 4-17 SCOLIOSIS SECONDARY TO SHORT LEG SYNDROME. Erect AP Lumbar Spine. Observe that the

pelvis is not level, being low on the reading left with a compensatory left lumbar rotary scoliosis. COMMENT: On asupine study these changes were not present, highlighting the role for upright radiography for the detection of short

leg syndrome.

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Figure 4-18 SCOLIOSIS SECONDARY TO SHORT LEG SYNDROME, COMPLICATIONS. A. Erect AP

Lumbopelvic. Note the pelvic unleveling (obliquity), low on the reading right, with a compensatory mild midlumbarrotatory curvature convex to the side of pelvic obliquity. Degenerative changes are present at the apical upper

lumbar segments on the concave side (arrows). B. AP Hip Spot. On the side of the short leg note the increasedprominence of the primary compressive trabeculae in the femoral neck (arrow).

Table 4-3 Orthoradiographic Findings in Short Leg Syndrome







g p g g y

Short leg side

Pelvic and sacral unleveling (obliquity)

Convex lumbar scoliosis

Vertebral body intersegmental-coupled physiologic rotation

Intervertebral disc degeneration (osteophytes, disc wedging)

Deeper endplate nuclear impressions, which are displaced medially

Decreased lumbosacral facet joint angle

Sacroiliac and hip osteoarthritis

Femoral neck thickening of the primary compressive trabeculae

Femoral neck medial cortical thickening (buttressing)

Long leg side







Vertebral body wedging

Compensatory contralateral scoliosis in the thoracic spine

Antalgic (Sciatic Scoliosis)

In acute low back pain syndromes, the lumbar spine is often seen directed off the midline without compensatory

coupled movements or laterally wedged disc spaces (towering). This configuration often denotes muscle guardingand spasm developed to reduce mechanical

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irritation of a nerve root. (Fig. 4-19) In patients with sciatic pain and concurrent disc herniations, a tilt toward the side

of pain has been linked to more medially placed disc lesions, whereas spinal tilt away from the side of pain is usuallythe result of a herniation occurring laterally to the affected nerve root. (47)









Figure 4-19 ANTALGIC SCOLIOSIS. Erect AP Lumbar Spine. There is acute lateral flexion at the L4 segment withfailure of the vertebrae to rotate, despite the lateral spinal deviation. COMMENT: This patient exhibited classic

clinical signs of L4 disc protrusion. The lack of intersegmental-coupled motion is often a sign of muscle spasm

caused by pain.RADIOLOGIC ASSESSMENT

Imaging is the most definitive and important diagnostic tool in the assessment and management of the patient withscoliosis. (1) A number of non-radiologic methods, such as Moire contourography and back contour devices, have

been employed. (2) The role of the radiograph is multiple: (a) determining cause; (b) evaluating curvature, including









site, magnitude, and flexibility; (c) assessing bone maturity; (d ) monitoring progression or regression; and (e) aiding

in the selection of appropriate treatment. A wide variety of factors are involved in the process of obtaining practicalclinical information while avoiding unnecessary radiation exposure.

Equipment

In producing a quality radiograph for scoliosis assessment, it is desirable to use a radiography system capable ofexposures at 84 inches (200 cm). A minimum capacity for such exposures would be a 125-kilovolts peak (kVp),

300-mA machine. Use of high-frequency generators (100 kHz) is optimal. (3) A grid ratio of no less than 10:1, in

combination with rare earth screens, produces acceptable images while reducing the radiation dose. (3,4,5)Similarly, the use of split screens to compensate for differing body thicknesses should be avoided; balancing

filtration at the collimator is preferred. (6) Technique factors depend on the individual patient, but a minimum of 90

kVp is recommended. (3,7)Sectional AP films should be taken when the patient’s body thickness measures > 24 cm. Gonadal protection must

be applied in all instances of scoliosis evaluation, in both the AP and the lateral projections. In follow-upexaminations, the majority of the pelvis should not be exposed, with the exception of the sacral base and the iliaccrests. Visualization of these structures will allow continuing and adequate evaluation of the iliac epiphysis sign

(Risser’s sign). Lateral collimation on AP films should be as close as practical, without compromising necessary rib

and curvature details.Specialized Shields and Fi lters.

Numerous shields have been developed to reduce doses to radiosensitive organs, such as the breast, thyroid, and

gonads. (6) These are especially useful on lateral radiographs because of the higher level of exposure necessary to

produce this film. Additional filtration is also instrumental in substantially decreasing the absorbed dose andobtaining a better quality image. (8)

Standard Radiographic TechniquesAn accurate radiographic review of scoliosis requires the clinician to be able to assess the condition for the

underlying cause and incorporate essential mensuration procedures to evaluate the curve. (Table 4-4)

Table 4-4 Radiographic Examinations in Scoliosis

Projection Indications and Information

Standard techniques

















Standard techniques

Erect AP Curve analysis; contributing causes

Erect lateral Sagittal curvatures (kyphosis, lordosis)

Lateral bending Flexibility

Left hand, wrist Skeletal age

Supplementary techniques

Chest Cardiopulmonary status

Contrast studies

Angiogram Vascular compromise; neoplasm

Gastrointestinal Duodenal obstruction

Genitourinary Kidney anomalies; obstruction

Myelogram Cord integrity; anomalies; stenosis







Myelogram Cord integrity; anomalies; stenosis

Derotated Anatomy; anomalies

Erect AP Reduction of radiation dose

Flexion-extension Sagittal curve; flexibility

Lumbosacral spot

AP Anomalies

Lateral Spondylolisthesis

CT Osseous detail

MRI Spinal lesion

Obliques Fusion and instrumentation status

Supine Flexibility

Tangential Efficacy of rib hump surgery







Tangential Efficacy of rib hump surgery

Tomography Anatomy; abnormalities

Traction Flexibility in neuromuscular disease

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ProjectionsErect AP and Lateral Projections.

The erect AP and lateral projections are the absolute minimum required for accurate assessment of any scoliosis.

Preferably the AP projection should be done by a single exposure on a 14- by 36-inch cassette to allow for total andcontinuous curvature evaluation. (3) However, if such equipment is not available, sectional projections can be used

just as effectively. The disadvantages of the singleexposure full-spine projection are the irradiation of unnecessary

body parts, sacrifice of bone detail for pathology, and expense of the equipment necessary to do the projectionsadequately. (Fig. 4-20) Wherever possible a long focal-film distance; rare earth screens, density-equalizing filtration;

collimation; optimal kilovoltage; and lead shielding of breasts, thyroid, and gonads should be used. (3) The PA

projection significantly reduces the dose to sensitive tissues. It is preferable to include the sacrum, iliac crests, andall spinal segments at least to the upper cervical complex. In some institutions, once the initial study has been

performed and the relatively rare complication of cervical spine involvement is excluded, AP views are exposed fromT3 to the sacrum to reduce thyroid irradiation. The lateral projection should be taken with the convexity of the curveplaced toward the bucky to adequately differentiate the vertebral body and disc.










Figure 4 20 AP FULL SPINE The right primary thoracic scoliosis is stabilized with a short segment Harrington’s







Figure 4-20 AP FULL SPINE. The right primary thoracic scoliosis is stabilized with a short-segment Harrington’srod. COMMENT: Technical problems, especially in obtaining adequate collimation, make it di fficult to reduce patient

dose and exclude radiosensitive tissues such as the breast, thyroid, and gonads when obtaining a full spine

projection. (Courtesy of Craig Reese, DC, Boulder, Colorado.)Mensuration

The four basic spinal parameters evaluated in scoliosis are curvature, rotation, flexibility, and skeletal maturation.

Curvature Measurement.The two most popular measuring methods are the Cobb-Lippman and Risser-Ferguson systems. The Cobb-

Lippman method is the most accepted standard for quantifying scoliotic deviation. (9)

Cobb-Lippman Method.The first method was introduced by Lippman in 1935 and popularized later by Cobb. (10) (Figs. 4-21 and 4-22) On

the AP radiograph, a line is drawn along the superior border of the cephalad end vertebra. A similar line is drawn

along the inferior surface of the caudad end vertebra. If the endplates are not visible, the bottom or tops of thepedicles can be used. Curve magnitude can be measured by assessing the horizontal angle formed at the natural

intersection of these lines or intersecting perpendicular lines can be drawn. Perpendicular lines are erected from

each endplate line, and the vertical (not horizontal) angle formed by their intersection is measured. Seven groups arecategorized, according to Cobb’s angle: group 1, 0-20°; group 2, 21-30°; group 3, 31-50°; group 4, 51-75°; group 5,

76-100°; group 6, 101-125°; and group 7, ≥126°.

The Cobb-Lippman method gives larger measurements than the Risser technique by an average of 25%, or about10°. (9,11) With larger curves, this percentage difference increases, and some have advocated using the Risser-

Ferguson method to reduce theP.421

discrepancy, but this practice is discouraged. The Cobb-Lippman procedure has the distinction of being more easily

applied and reproducible by different observers. (12) In double curvatures, both curves should be measured.















Figure 4-21 CURVATURE MENSURATION. A. Cobb-Lippman Method. The end vertebrae are located, and linesare drawn on their appropriate endplates. Perpendiculars are erected to the endplate lines, and the intersecting

acute angle is measured. B. Risser-Ferguson Method. A dot is placed in the center of each end vertebra and in the

apical segment These are then joined and their intersecting acute angle is measured COMMENT: The Cobb







apical segment. These are then joined, and their intersecting acute angle is measured. COMMENT: The Cobb-Lippman method is the most commonly used mensuration procedure in scoliosis. When comparing sequential

studies it is important to choose the same end vertebrae when making the measurements.







Figure 4-22 COBB-LIPPMAN METHOD OF MENSURATION. AP Thoracolumbar. Lines drawn perpendicular to the

endplates of the end vertebrae intersect on the concave side, where the angle is measured.







Figure 4-23 PEDICLE METHOD OF DETERMINING ROTATION. A. Grading System. Note that with increasing

degrees of rotation (shown from bottom to top) the pedicle on the convex side migrates medially. B. Nash-Moe

Grade +2 Rotation, AP Lumbar Spine. The pedicle on the convex side of the curve migrates medially and at L2almost lies in the midsagittal plane of the vertebral body (grade +2). At L4 the pedicle has moved only slightly (grade

+1). (Courtesy of William E. Litterer, DC, DACBR, Fellow, ACCR, Elizabeth, New Jersey.)

Risser-Ferguson Method.









g

Ferguson first introduced his methodology in the early 1920s and later published his findings along with Risser in the1930s and 1940s. (11,13,14) (Fig. 4-21) In this procedure, the centers of the end and apical vertebral bodies are

identified. These points are then connected, and the angle of intersection is measured.

Rotation Assessment.

Rotation is also measured on the AP radiograph and is invariably present in scoliosis. In the thoracic spine, it isintimately associated with the degree of external cosmetic deformity. The anterior column (vertebral body, disc)

rotates more than the posterior column (neural arch). (15)Spinous Method.

Cobb first described an evaluation based on the position of the spinous tip to the vertebral body. (10) It provides an

estimate of posterior vertebral deformity. (15) Spinous processes are prone to malformation and displacement andare frequently difficult to identify. Consequently, these structures should not be used to assess rotation.

Pedicle Method.

Described by Nash and Moe in 1969, the pedicle method is the most accepted technique of determining rotation.(16) (Fig. 4-23) The movement of the pedicle on the convex side of the curve is graded between 0 and +4 and is a

measure of anterior deformity. (15,16) CT examination of scoliotic vertebral rotation has demonstrated that the

pedicle method is not entirely accurate but is the most user friendly. (17) A vertebra with a Nash-Moe grade of 0, which is given when there is no apparent rotation, in fact may have > 10° of rotation. (17)

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Flexibility AssessmentFlexibility is defined as the degree of mobility within a scoliosis. This is an important parameter to assess because it

predicts not only the correctability of a scoliosis but also the risk for progression. To the surgeon, a lack of flexibilitymay reduce the likelihood of successful spinal fusion. The radiographic assessment of flexibility should be done

bilaterally and with the patient supine, but the evaluation is primarily made from the radiograph taken when the

patient is bending toward the side of convexity. In this position, the patient must laterally flex as much as possible.Cobb’s method is applied, and the degree of correction induced is the measure of flexibility. (Fig. 4-24) In non-

structural curves, the magnitude of the scoliosis changes while structural curves remain unchanged.Skeletal Maturation

Ascertaining skeletal maturity is vital to determining treatment and prognosis. While the potential for growth remains,there is the possibility of curvature progression. Three observations are used in this determination: comparing the






















p y p g p g

left hand and wrist with the Greulich and Pyle Atlas, observing the vertebral ring epiphyses, and observing the iliac

epiphysis.Left Hand and Wrist.

A spot AP radiograph is taken of the left hand and wrist in patients under 20 years of age. This is compared with the

Greulich and Pyle Atlas to ascertain the skeletal age of the patient, which is important in planning the treatmentregime. (5). In general, scoliotic females are more mature than normal between 11 and 12 years of age and less

mature between 15 and 17 years. (18,19) Practically interpreted this means that the growth period in scoliotic

females is lengthened. (20) It is important to note that the distal radial epiphysis closes at the same time as thevertebral body epiphysis.











Figure 4-24 FLEXIBILITY EVALUATION BY LATERAL BENDING. A. Erect, Neutral Position. Observe the presenceof a left lumbar and right thoracic curvature. B. Left Lateral Bending. Note the left lumbar curve disappears, indicatingthat it is non-structural. C. Right Lateral Bending. The right thoracic curve remains unchanged, indicating that it is

structural. COMMENT: When there is failure of a curvature to correct on lateral bending, the curvature can be

interpreted as being irreversible (structural) and also non-progressive.







Figure 4-25 RADIOGRAPHIC DETERMINATION OF SPINAL MATURITY. A-C. Iliac Epiphysis. D-F. Vertebral Body

Epiphysis. The two most reliable signs of maturation are the status of the iliac and vertebral body epiphyses. Whenthey are both fused and no longer visible, spinal maturation is complete and curvature progression is less likely.

Vertebral Ring Epiphyses.

Vertebral ring epiphyses are normal traction epiphyses at the peripheral body margins. Although they do not

contribute to vertical vertebral body growth, their fusion to the body rim closely parallels the maturation of spinalgrowth. (Fig. 4-25) The recognition of this fusion is the

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most accurate indicator of completed spinal growth and can be interpreted as a strong inhibiting factor to future

scoliotic progression.








Figure 4-26 ILIAC EPIPHYSIS (RISSER’S SIGN). A. Grading System. The epiphysis first appears at the

anterosuperior iliac spine and gradually progresses posteromedially before fusing to the ilium. Five grades arerecognized, one for each quarter ossified—1, 2, 3, 4, and 5 (when complete osseous fusion has occurred). B. Grade

4 Risser’s Sign, AP Pelvis. The entire epiphysis is present (arrow) but remains separated by the growth plate visibleas a thin radiolucent line (arrowheads). COMMENT: The distal radial epiphysis closes at the same time as the iliac

epiphysis and the vertebral body epiphyseal endplates.

Iliac Epiphysis (Risser’s Sign).The recognition of the iliac crest epiphysis (apophysis) as an indicator of spinal maturity was first noted by Risser in

1948 and later confirmed. (21,22,23,24) In the majority of individuals the apophysis first appears laterally near the

anterior superior iliac spine and progresses medially toward completion at the posterior superior iliac spine(capping). The degree of completion is estimated by percentage and a grade, assigned as follows: grade 1, ≤25%;

grade 2, 26-50%, grade 3, 51-75%; grade 4, 75-100%. When the epiphysis is fused to the ilium, it is graded 5.

(Figs. 4-25 and 4-26)The process of capping usually begins in boys at the age of 16 and in girls at the age of 14. From the time of

appearance to complete excursion to the posterior superior iliac spine a time period of 1 year has usually elapsed. It

then will take 2-3 years for complete osseous union to occur. This pattern of formation and closure parallels theformation and progression of the scoliosis. In the preadolescent child (10 -15 years), before the appearance of the

iliac epiphysis, it is usual for the curve to show the greatest rate of progression. (23) Once the epiphysis becomes

visible, curve progression slows and eventually ceases when the epiphysis fuses. A Risser grade 4 in females and

d 5 i l ll i l th d f i (25)















grade 5 in males usually signals the end of curve progression. (25)Supplementary Techniques

Numerous specialized projections are available to provide additional information. (Table 4-4)

Chest. Specific evaluations of the lungs and heart should be obtained periodically to establish any alteration incardiopulmonary status, especially cor pulmonale and congestive heart failure. In neonates and children, co-existing spinal segmentation defects may suggest anomalies of the heart, trachea, or lungs. Echocardiograms

of the heart are employed specifically for valvular anomalies, vascular anatomy, and septal defects.

Contrast examinations. Occasionally, these studies may be employed to better evaluate certain body systems.CT myelography may be employed to evaluate spinal cord integrity, congenital anomalies, and stenosis if MRI

is contraindicated or not available. CT scans of the abdomen and chest may be used to identify co-existing

cardiac, pulmonary, renal, and other visceral anomalies. Gastrointestinal studies are used when abdominal

symptoms suggest duodenal obstruction by the superior mesenteric artery as the curvature is corrected. (26)Angiograms are rarely used except when vascular compression or vascular neoplasm in the cord is

suspected.

Derotated view. This view is used only in severe kyphoscoliotic curves (> 100°). By rotating the patient, it ispossible to reduce the effects of segmental rotation, which allows for better evaluation for underlying

anomalies. (27)

Flexion-extension. These are analogous to the lateral flexion views for flexibility evaluation. Their main purposeis to demonstrate the degree of mobility within the curvature in the sagittal plane.

PA. Various studies have shown significant reductions in radiation doses to such radiosensitive structures as

the thyroid, breasts, and active bone marrow by performing the frontal film in a PA position. (6,22,28,29,30) Asan

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example, this projection reduces the dosage to the breast by a factor of approximately three, from 60 mRad (0-

60 Gy) to 20 mRad (0-20 Gy). However, inherent in the placement of the vertebrae farther from the film are themagnification, the loss of geometric sharpness, and a change in the measured Cobb’s angle, thus making AP

comparisons of dubious value. (22,29)

Lumbosacral spot views. Owing to technical underexposure, the details of the lumbosacral region are

f tl b d A AP j ti ith h l d t b tilt f 20 30° ill h th j ti l i l l


















frequently obscured. An AP projection with a cephalad tube tilt of 20-30° will show the junctional region clearly.(31) In addition, a lateral erect projection may demonstrate a spondylolisthesis frequently seen in conjunction

with scoliosis, especially if rotation is evident on the frontal radiograph. (32,33)

Oblique. The object of these films is usually to assess the status of a previous bone graft or corrective

instrumentation. Additional information is also obtained, such as the integrity of the pars interarticularis andparaspinal soft tissues.

Segmented field radiography. A standard AP full spine radiograph is taken at the initial visit. (34) Transitionaland end levels are located from which the Cobb’s angles are constructed. Subsequent examinations, which

may follow with treatment, take only collimated, small field views of these same transitional and end levels, with

the Cobb method applied again. This technique reduces the radiation dose considerably.Supine. When compared with erect radiographs, the effect of gravity on the curve can be observed with this

view, which provides data on the curvature flexibility. An additional bonus is the improved structural detail that

is obtained in this position.Tangential (rib hump view). This view is used only when cosmetic surgery is contemplated for the posterior rib

hump. The patient faces the bucky and flexes forward; the X-ray beam is directed tangentially across the back.

If the vertebrae are seen to be rotated under the ribs, no surgery is performed because the patient will maintainthe hump even if the ribs are removed. (29)

Tomography. The depiction of obscured anatomic details and deformity have been examined by sequential

tomography but currently this method is being largely replaced by CT.

Traction. This is used only in patients with neuromuscular disease who are unable to perform lateral-bendingstudies unassisted. A supine projection is taken with traction applied to the head and feet, and the projection is

compared with the neutral AP film.

Written Reports

Clear, succinct, and accurate reporting of scoliosis is particularly important to direct clinical decision making andallow rapid comparisons with sequential studies. When scoliosis radiographs are analyzed, they are typically placed

on the viewing box in the PA direction so that the patient’s right is on the right side of the interpreter. In addition to thetraditional identification by name, age, institution, date, and file number, further information may be helpful. When

lateral-bending studies are being viewed, it is important to include the direction of bending and to identify the

projection as a lateral-bending study. It is also vital to identify whether the projections are being taken with the patient

erect or recumbent A framework for reporting should include at least nine components and mastering this












erect or recumbent. A framework for reporting should include at least nine components, and mastering thisprocedure will enhance verbal presentation of findings and clinical decision making. Clinical examples with reports

are presented in Chapter 15.

Description of imaging study. Assessment of the technical adequacy of the study, the views performed, thepatient position (whether erect or recumbent), and the dates of study need to be recorded.Location of curves. The regional location of the curvature is stated, such as, “In the lumbar spine.” (Fig. 4-1)

Curve direction. The side of the body to which the convexity is directed is referred to as the direction of

scoliosis. Dextroscoliosis is a curve convex to the right, and levoscoliosis is convex to the left.End and apical vertebrae. The end vertebrae and the apical vertebra should be identified in the report.

Rotation assessment. The relative positions of the pedicles silhouetted on the vertebral bodies is the most

reliable marker of vertebral rotation. (Fig. 4-23) Spinous process position is unreliable as a result of altered

growth secondary to asymmetrical muscle effects.Curve magnitude. The most common measurement employed is the Cobb-Lippman method, which ensures

the angles between the end vertebrae. The method of assessment should be stated in the report along with

curve magnitude and the landmarks used, for example, “A 35° dextroscoliosis is present between the superiorendplate of T4 and the inferior endplate of T11, using the Cobb method of assessment.” It is important on

comparison examinations that the same end vertebrae be used to maximize the reliability of interval

measurements. (Figs. 4-21 and 4-22)Cause. The majority of cases will have no origin definable on imaging, but a cause should be sought at all

times. Careful attention to vertebral shape, margins, and density should be applied to identify segmentation

anomalies, bone tumor infiltration, or other diseases. (Table 4-1)Skeletal maturity. Analysis of the iliac apophysis and its stage of fusion, vertebral body ring epiphysis fusion,

and the Greulich-Pyle staging of the left hand can assess bone age. This is important because curves tend to

progress until maturity is reached. (Figs. 4-25 and 4-26)Secondary complications. Careful scrutiny within the curve may reveal degenerative changes with loss of disc

height and osteophytes, kyphosis, lordosis, and even gibbus. Lateral vertebral wedging is common owing togrowth plate effects (Hueter-Volkmann principle). (Fig. 4-5) Frequently, endplate irregularities from Schmorl’s

nodes or Scheuermann’s disease can be seen. Co-existing spondylolysis or spondylolisthesis is also common

and can be readily overlooked.




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ADVANCED IMAGING TECHNIQUES

Beyond plain film examination, selective and judicious use of nuclear medicine, CT, and MRI can be important indetecting a cause for scoliosis, a pain site within a scoliosis, and surgical complications. (1)Nuclear Medicine

Triple-phase bone scan is employed in scoliosis, especially when pain is present, to assist in localizing a bony

abnormality. The four most common diagnoses elucidated on bone scan are active spondylolysis, osteoid osteoma,discitis, and Schmorl’s nodes. These may require single-photon emission computed tomography (SPECT) imaging,

which increases the sensitivity of the study significantly by acquiring CT-like cross-sectional images. Following

spinal fusion for scoliosis, hardware failure, infection, and pseudo-arthrosis can all be localized with bone scan.

Computed TomographyThin-section display by CT provides optimum assessment of bony detail. Multislice helical CT is especially useful

when investigating back pain following instrumentation because scatter artifact can be largely controlled. Helical CT

depicts bone-metal interfaces, providing evidence of loosening, fracture, and pseudo-arthrosis. In patients who arenot able to undergo MRI examination, multislice helical CT with myelography provides an excellent alternative.

Magnetic Resonance Imaging

The primary indications for performing MRI in idiopathic scoliosis are unexplained severe headaches; neck pain andstiffness with hyperextension; back pain; and clinical findings such as ataxia, cavus foot, focal neurologic signs, and

diminished perception of light touch, pressure, position, or pain. A left-sided scoliosis, especially in a patient under

11 years of age with curves < 15°, progressive curves, or known segmentation anomalies, requires evaluation of theentire spinal cord and brain, especially the posterior fossa. (2,3) Identified causes of scoliosis that can be

demonstrated on MRI include intracranial or cord neoplasms, syringomyelia, Arnold-Chiari malformation, tethered

cord, and bone tumor (including aneurysmal bone cyst, osteoid osteoma, osteoblastoma, and Ewing’s sarcoma). (4)CLINICAL CORRELATIONS

Application of the radiographic information is vital to the diagnosis, treatment, and evolving management ofscoliosis. Specific applications include selection of therapy, monitoring patient response, and long-term

assessment.

Therapy

Therapy selection is based on the synthesis of all clinical and imaging information The major objectives in selecting











Therapy selection is based on the synthesis of all clinical and imaging information. The major objectives in selectinga therapeutic regime hinge on curve progression and its effect on cosmetic appearance and bodily function.

Approximately 25% of all curves will show some degree of progression. (3) Indicators of likely progression include

curvature pattern, age, onset of menarche, and an absent (grade 0) or early (grade 1) Risser’s sign. (5) Curve

patterns at the highest risk of progression should be braced earlier. These include double primary curvatures (twocurves in one region) and primary lumbar with compensatory thoracic curves. (6) The lumbar component is the most

likely component to progress. In addition, other factors, such as the magnitude of the curve (curves > 20° are threetimes more likely to progress), flexibility, and family history, should be considered. (5,6)

The major therapeutic decision is among three alternatives: close observation, bracing, and surgery. (7) There is no

consensus of opinion on the usefulness of other therapies. The use of surface electrical stimulation in some studieshas been as effective as the Milwaukee brace in halting progression (8), whereas other studies have yielded

disappointing results. (9,10) Combining chiropractic treatment with electrical stimulation has been shown with case

studies to reduce curve magnitude. (8) In minor curves (< 20°) there is general agreement that the patient does notrequire bracing (11,12); however, in view of possible rapid progression during the growth period (10-15 years),

these patients must be frequently and carefully examined for signs of increasing deformity. Radiographic

examination every 3 months should be done as part of this monitoring process. (13,14) If more than a 5° increase isdemonstrated between examinations, bracing should be contemplated if it is thought that there is substantial skeletal

growth remaining. (12) In addition, significant rotation and rib hump also are factors indicating need for intervention.

Exercise has not been shown to decrease scoliosis, but it does have value in improving posture, flexibility, muscular

tone, and psychological awareness. Chiropractic spinal manipulation frequently decreases associatedmusculoskeletal symptoms.

Bracing.Indications for bracing include curves that are flexible, skeletally immature, between 20° and 40°, and progressive in

nature. (5,11,15) The most commonly used brace is the Milwaukee brace. (16) Its purpose is not to correct a curve

but to prevent further progression, although some curve reduction may occur with bracing. The brace functions byexerting longitudinal traction between the occiput and the pelvis, with pressure pads appropriately placed to limit

rotation and lateral displacement. Physiologically, the cumulative effect is to decrease the curvature and thesegmental torsion. In addition, this aids in decreasing the compressive forces on the discovertebral growth plate and

helps prevent the lateral wedged deformities of the vertebral bodies. The brace is worn for 23 hr per day untilskeletal maturity and should be combined with a specific exercise regime. (11,12) At cessation of therapy, a

weaning period of 6-12 months is usually necessary with gradually increasing periods without the brace




























weaning period of 6 12 months is usually necessary, with gradually increasing periods without the brace.

Radiographs should be obtained every 3 months during this period to evaluate for stabi lity or progression. Ifprogression is evident, the bracing time must again be increased.

Surgery.

Surgical intervention is used when an underlying abnormality can be treated, rapid progression is occurring in animmature spine, or the curve is > 40°. These criteria are not definitive (12,17); however, it is generally accepted

among surgeons that a lack of flexibility may reduce the likelihood of an successful outcome. Occasionally milder

deformities may be surgically stabilized for cosmetic reasons. The most common surgeries performed include theinsertion of Harrington’s rods and the Dwyer procedure of wire cable and screws. (18) (Figs. 4-27 and 4-28)

P.426












Figure 4-27 HARRINGTON’S ROD PROCEDURE. A. AP Thoracic Spine. Two vertical rods are placed on either

side of the spine and anchored to the vertebrae at either the lamina or the base of the transverse processes. Nocross-links have been used. B. Lateral Thoracic Spine. The position of the hooks is confirmed beneath the laminae.

COMMENT: These remain the most common fixation methods in scoliosis, with additions such as bone fusion,

sublaminar wires, and extension of the rods across the sacroiliac joints (Luque rods). (Courtesy of William E.

Litterer, DC, DACBR, Fellow, ACCR, Elizabeth, New Jersey.)









, , , , , , y )









Figure 4-28 DWYER’S PROCEDURE. AP Lumbar Spine. The intervertebral discs are removed, screws areinserted, and the connecting wire is shortened to compress the vertebrae together and reduce the flexibility for

progression of the curvature. (Courtesy of William E. Litterer, DC, DACBR, Fellow, ACCR, Elizabeth, New Jersey.)

P.427

Monitoring and Long-Term Assessment

In both the braced and unbraced patient with scoliosis, careful and frequent examination should be performed. Aradiographic study should be done every 3-4 months until skeletal maturity, as demonstrated by closure of the iliac

epiphysis. Once a brace has been removed, an annual examination for 5 years is suggested to observe and monitor

any delayed tendency for progression. If the curve does show progression, surgical stabilization may be indicated. Insurgical cases, radiographs will aid in the placement of stabilizing instruments and graft material. During the

postoperative period the degree of correction, the integrity of the fusion, and possibility of complications can beassessed. Postfusion radiographs show decreased Cobb’s angles of around 35%, but the shape of the curve andapical vertebral rotation remain unchanged. (19,20) Over an extended time period the radiographic examination can

be used to evaluate superimposed degenerative changes and progressive spinal changes. Those fusions that

extend below L2 have a higher incidence of discal syndromes, requiring further surgery at a later time. (21)COMPLICATIONS

Unrelated to TreatmentCardiopulmonary Complications.

In more severe thoracic curvatures, restricted rib cage movement and lung volume ultimately produce pulmonary

hypertension with subsequent right-sided (cor pulmonale) and left-sided congestive heart failure. (1) Congestive

heart failure is the single most common direct cause of death in the patient with severe scoliosis. Altered lung













ventilation also predisposes the individual to pulmonary infection and dyspnea.

Degenerative Spinal Arthritis.

Loss of disc height, osteophytes, and intersegmental instability frequently accompany adult scoliosis and

occasionally even adolescent scoliosis. (2,3,4) Distinctively, these degenerative changes are most pronounced onthe concave side of the curve and extend to involve other stressed articulations, including costotransverse,

sacroiliac, and hip joints. (Fig. 4-29) Lateral listhesis of the apical and subadjacent segments is related to facetarthrosis and is often symptomatic. (5) The most common area of secondary spinal pain from a thoracic scoliosis is

the lumbar spine. (4) Secondary spatial compromise of the central and lateral spinal recesses may result in nerve

root entrapment syndromes. (6) Degenerative changes may precipitate an increase in curve magnitude (collapsingscoliosis).

Curvature Progression.

The most rapid and severely deforming time period for scoliosis is in the adolescent growth spurt (age 12-16 years), when the curve may increase at the rate of 1° per month. (3) In the adult, progression does occur but is relatively less,

in the range of 10-15° over the life-time. (2,3) Larger magnitude curves typically show greater progression.

Fatigue and Joint Dysfunction Syndromes.Altered biomechanical spinal stresses frequently produce asymmetric muscle and joint loadings. Muscular and

ligamentous strain ensues, and spinal and sacroiliac joints become inflamed and altered from their normal

kinematics, which all contribute to produce significant pain, discomfort, and disability. (7,8) These symptoms arefrequently the most immediately debilitating feature in a patient with scoliosis. (4) Sites of pain in lumbar curves

include the curve convexity (most common), the lumbosacral region, the curve concavity, and the costoiliac region

with impingement of the ribs over the iliac crest (rare). (8)





















Figure 4-29 SCOLIOSIS WITH COMPLICATING DEGENERATIVE ARTHRITIS. AP Lumbar Spine. Observe the

severe facet arthrosis on the convex side low in the curve (arrows). At the apex of the concavity disc degeneration,







spondylophytes and lateral listhesis are evident (arrowheads).

Radiation Exposure.

A considerable amount of concern has focused on the long-term effects of repeated radiologic examinations. The

usual patient undergoing conservative therapy with bracing over 3 years has an average of 22 radiographs taken.The chance of an increased risk of malignancy in patients with scoliosis appears to be minimal compared with the

natural incidence in the general population (0.2% for breast carcinoma; 5% for leukemia). (9,10,11)Pregnancy.

The implications for pregnancy in the setting of scoliosis remain sketchy. In general, severe lumbar curves may be

associated with obstetrical difficulties, whereas severe thoracic curves may be linked to other medical problems.(12) A higher incidence of premature delivery has been recorded. (13) Cesarean rates are not increased, nor is the

incidence of back pain during pregnancy, even if fusion has been performed. (14,15) Whether a pregnancy has a

significant effect on curve progression is inconclusive. (8,16)P.428

Related to TreatmentNon-surgical and surgical measures used in the treatment of scoliosis may produce a wide range of complications.

Non-Surgical Complications.

The majority of deleterious side effects arise from the use of external braces and supports. Psychologically the

patient undergoes mental stress. In long-term bracing, superficial skin irritations may be a persistent problem, as aresult of either sweating or allergy. It is rare for pressure sores to develop. Occasionally nerve compression may

occur with numbness and paresthesias, especially of the anterior femoral cutaneous nerve and, less commonly, ofthe brachial plexus. With curvature correction, compression of the duodenum under the superior mesenteric artery

may create obstruction with nausea and vomiting (cast syndrome). (17) In the past the chin rest on Milwaukee braces

frequently produced lower facial and dental abnormalities, but these are rare findings today. (18)

Surgical Complications.During the operative procedure, cardiac arrest and spinal cord injury are the most feared complications. Early

postoperative problems include respiratory distress, infection, and loosening of the fixation device. Later, after

release from the hospital, infection may still supervene. However, the most frequent complications are pseudo-

arthrosis of the fusion (15% of cases) and instrumentation failure. (19) (Fig. 4-30)


























Figure 4-30 FRACTURED HARRINGTON’S ROD. AP Thoracic Spine. Observe the fracture with mild displacement(arrow) of the rod near its upper end. The sublaminar wires inferiorly remain intact. (Courtesy of Noel J. Patterson

DC, MIR, Perth, Western Australia.)

Medicolegal Implications

SCOLIOSIS

In all cases of scoliosis a cause must be sought. There needs to be a systematic evaluation both clinicallyand radiologically to identify segmentation defects, neuromuscular disorders, neurofibromatosis, and spinal

cord and vertebral tumors. The diagnosis of idiopathic scoliosis is a diagnosis by exclusion.

In idiopathic scoliosis appropriate follow-up radiologic examination must be considered at a minimum of 3- to4-month intervals during the growth phase (12-16 years) to monitor for progression. Failure to recognize

progression of scoliosis during the growth phase may delay more aggressive intervention and result in more

severe deformity and long-term complications. Individuals who possess high-risk indicators of likelyprogression should be followed more closely (double primary or lumbar primary curvature, younger age, early

menarche, low-grade Risser’s sign, curves > 20°, positive family history).

Pain in the presence of scoliosis, especially in children, needs to be investigated to exclude a pathologiccause. This may include additional imaging, especially nuclear bone scan and MRI.

Radiographs must be of high quality taken with stateof-the-art equipment (high-frequency generators, rare

earth screens, and so forth) to minimize radiation dose because multiple examinations are often requiredduring the growth period. Removal of radiosensitive tissues from the irradiated field, either by collimation,

filters, or shielding, should be a priority. The frequency of radiographic examinations should be minimized as

much as possible.

The technical inadequacies for pathologic evaluation, such as reduced bone detail of full spine exposures,should be considered When clinically indicated or if there is a questionable area noted on the full spine









should be considered. When clinically indicated or if there is a questionable area noted on the full spine

radiograph, sectional or spot films should be obtained.

Measurements must be accurate and consistent. The method of choice remains the Cobb-Lippman method,

which hinges on the correct choice of end vertebrae, accurate placement of lines, and accurate anglemeasurement. It is critical to use the same landmarks and end vertebrae at subsequent examinations to

provide meaningful comparative data on curvature development.Complications may arise and need to be recognized. These may include pulmonary hypertension and heart

failure, degenerative spinal syndromes, curve progression, and joint dysfunctions. In patients with previous

surgery, infection, bony fusion, or hardware failure can supervene.In idiopathic scoliosis, claims for reducing or arresting further progression of curvatures with conservative

methods should be made with caution. These may result in unrealistic expectations and a false sense of

security in light of the unpredictability of the deformity.

P.429

CAPSULE SUMMARY Scoliosis

General Considerations

Scoliosis: from Greek word skolios, meaning “twisted or crooked”; lateral deviation of the spinal column.

Classification and Terminology

Classified according to origin (Table 4-1) and location.Specific standardized terminology is used in the discipline.

Clinical Features

Structural scoliosis: a fixed deformity that does not correct on lateral bending.

Idiopathic scoliosis: the most common scoliosis; includes infantile, juvenile, and adolescent.Infantile scoliosis: 0-3 years; male dominant; the majority disappear.

Juvenile scoliosis: 3-10 years; female dominant; 30% progress








Juvenile scoliosis: 3 10 years; female dominant; 30% progress.

Adolescent idiopathic scoliosis: 10 years of age until skeletal maturity; more common in females (9:1); usuallyright thoracic, wedged vertebrae (Hueter-Volkmann principle); most rapid growth between age 12 and 16.

Congenital scoliosis: structural anomalies (block vertebra or hemivertebra, pedicle bars); short curve; highincidence of genitourinary anomalies.Neuromuscular scoliosis: nerve or muscle disease (muscular dystrophy, cerebral palsy); long curve convex to

weak side.

Neurofibromatosis: mesoectodermal dysplasia; scoliosis common, often short and angular kyphosis, withvertebral dysplasia.

Others: infection; radiation; trauma; degenerative joint disease; neoplasm.

Non-structural scoliosis: deformity fully corrects on lateral bending.

Cause: leg length deficiencies; antalgia.Complications of scoliosis: cardiopulmonary disease; degenerative arthritis; curve progression; pain;

radiation-induced abnormalities; psychological disturbances; nerve palsies; infections; pseudo-arthrosis;

instrumentation failure.

Radiologic Assessment

Plain film: initial study performed erect, including cervical spine with lateral projections of spinal regions; follow-

up analysis may extend only from T2 or T3 to upper sacrum to reduce dose.Standard projections: erect AP and lateral full spine; right and left lateral bending; left hand and wrist.

Supplementary projections: many; applied to specific situations. (Table 4-4)

Full spine technology: 84 inches (200 cm) tube-film distance; appropriate collimation; compensating filtration;rare earth screens.

Measurements: curvature—Cobb-Lippman method; rotation—pedicle method; flexibility—lateral flexion;

skeletal maturation—left hand and wrist, vertebral ring epiphyses, iliac epiphysis (Risser’s sign).MRI: used for further evaluation of scolioses that are congenital, progressive, painful, and toward the left;

unexplained severe headaches, neck pain, and stiffness with hyperextension; back pain; additional indicators

include clinical findings such as ataxia, cavus foot, focal neurological signs, and diminished perception of light

touch, pressure, position, or pain.Bone scan: painful scoliosis to localize a bone tumor infection spondylolysis or fixation failure








Bone scan: painful scoliosis to localize a bone tumor, infection, spondylolysis, or fixation failure.

Therapy Selection

Indicators of progression: double curvatures; young age; early onset of menarche; absent or early Risser’ssign.

No treatment: < 20°, but must be monitored carefully every 3 months; an increase of > 5° between

examinations should be braced.Bracing: flexible; immature; 20-40° curves, which are progressive; Milwaukee brace common; evaluated every

3 months until maturity, then weaned gradually.

Surgery: abnormality; progression; > 40°; Harrington’s rods; Dwyer’s procedure.

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16. Bloom RA, Gheorghiu D, Verstandig A, et al.: The psoas sign in normal subjects without bowel preparation: Theinfluence of scoliosis on visualization. Clin Radiol 41:204, 1990.






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2. Goldberg CJ, Moore DP, Fogarty EE, Dowling FE: Left thoracic curve patterns and their association withdisease. Spine 24(12):1228, 1999.

3. Schwand RM, Hennrikus W, Hall JE, Emans JB: Childhood scoliosis: Clinical indications for magnetic resonanceimaging. J Bone Joint Surg 77A:46, 1995.4. Herzenberg JE, Waanders NA, Closkey RF, et al.: Cobb angle versus spinous process angle in adolescent

scoliosis. Spine 15:874, 1990.

5. Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. JBone Joint Surg 66A(7):1061, 1984.

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7. Farady JA: Current principles in the nonoperative management of structural adolescent idiopathic scoliosis. PhysTher 63(4):512, 1983.

8. Fisher DA, Rapp GF, Emkes M: Idiopathic scoliosis: Transcutaneous muscle stimulation versus the Milwaukee

brace. Spine 12:987, 1987.







p9. Aspegren DD, Cox JM: Correction of progressive idiopathic scoliosis utilizing neuromuscular stimulation and

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11. Keim HA: The Adolescent Spine. New York: Grune & Stratton, 1976.

12. Calliet R: Scoliosis: Diagnosis and Treatment. Philadelphia: FA Davis, 1978.13. Pearsall DJ, Reid JG, Hedden DM: Comparison of three noninvasive methods for measuring scoliosis. Phys

Ther 72:648, 1992.

14. Denton TE, Randall FM, Deinlein DA: The use of instant moire photographs to reduce exposure from scoliosisradiographs. Spine 17:509, 1992.

15. Tojner H: Olisthetic scoliosis. Acta Orthop Scand 33:291, 1963.16. Blount WP, Schmidt AC, Keever D, et al.: The Milwaukee brace in the operative treatment of scoliosis. J BoneJoint Surg 40A:511, 1958.

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