April 2007 - Division of Biology and Medicine - Brown University

Idiopathic Scoliosis In Children: An Update
The diagnosis of scoliosis in a growing
child is often a cause for great concern
for the patient’s family and primary physician.
Treatment in the past often involved
lengthy hospital stays, prolonged
bed rest, and postoperative casting. Even
patients treated non-operatively suffered
the stigma of the Milwaukee brace, a
metal framed structure extending from
the hips to the chin, worn 23 hours daily.
Modern insight into the potential causes
of scoliosis, the evaluation of a child with
spinal deformity, and advanced operative
and non-operative treatments allow successful
treatment of patients of all ages
with scoliosis.
Craig P. Eberson, MD
BACKGROUND
Scoliosis is defined as a lateral curvature
of the spine exceeding 10 degrees as
measured on a radiograph using the
Cobb method. (Figure 1) While some
patients may present with pain, the majority
of patients with scoliosis are asymptomatic.
1 Patients and their families may
notice an asymmetry of the waist, a rib
hump, or a difference in breast size due
to spinal rotation associated with the
curve. Most patients are diagnosed
through a screening program, either by
their primary care provider or through a
school program.
The cause of scoliosis remains the
subject of intense investigation.
While the cause of idiopathic
scoliosis is unknown,
recent investigations have
pointed to a genetic link, as
well as other etiologic factors.
2,3,4,5
Although a single
“scoliosis gene” has not been
found, studies of families
with a high incidence of
scoliosis have revealed several
potential candidates. 4 As in
all disorders, the diagnosis of
“idiopathic” scoliosis presumes
the exclusion of known
causes. A thorough investigation
into possible etiologies
must be undertaken prior to treatment.
(Table 1)
HISTORY AND PHYSICAL EXAM
Evaluation of the patient with scoliosis
includes a thorough history and physical
examination. A history of pain, numbness,
bladder dysfunction, headache, weakness
or dysesthesia should be sought. A family
history of scoliosis, connective tissue disorder,
or neurologic disorder is also relevant.
Physical exam includes a neurologic
examination, including reflexes. The abdominal
reflex is performed by stoking
each quadrant of skin above and below
the umbilicus. The umbilicus should move
toward the stimulus symmetrically. Asymmetric
reflex may indicate the presence of
a neurological problem either in the spinal
cord or the brain. Testing for ligamentous
laxity (i.e. Marfan Syndrome), a skin
exam to look for lesions associated with
systemic disease (i.e. Neurofibromatosissee
Figure 2) as well as an assessment of
the spine is performed. The location of
the curve, degree of rotational prominence,
and spinal balance (head centered
over the pelvis) are noted. The Adams
forward bending test is the most commonly
used screening examination for
scoliosis. In this test, the rotational component
of the curvature is visualized by
having the patient bend forward and view-
Table 1. Potential Etiology of nonidiopathic scoliosis
Neurologic
Tethered spinal cord
Syringomyelia
Cerebral palsy
Muscular dystrophy
Freidrich’s Ataxia
Other neuromuscular disorder
Connective tissue disorder
Marfan’s syndrome
Ehlers Danlos syndrome
Figure 1. Cobb Angle. Lines are drawn parallel to the
endplates of the most tilted vertebrae above and below
the apex of each curve. The angle formed by the
intersection of the lines drawn perpendicular to the
endplate lines is the Cobb angle (*). Modern digital
radiographs allow rapid, easy calculation of these lines
Syndromic
Beal’s syndrome
Rett syndrome
Other
Post-sternotomy
Thoracogenic (post thoracic surgery)
VOLUME 90 NO. 4 APRIL 2007
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