Chapter 3 Index

A. General

B. Skin

C. Orthopedics

Orthopedic Exam of the Teenager: Idiopathic Scoliosis

General Information: While males and females are affected equally, females have a much greater incidence of progression to severe scoliosis than males.

Is Screening in School Systems Justified: Not clear.  Many more normal children get referred than those with true scoliosis.  Recent study: 92/2242 children screened were referred; treatment needed in only 5 children, no treatment necessary for the remaining.

Incidence: The overall prevalence of curves less than 20 degrees is 3-5%, while the incidence of curves > 20 degrees is 0.5%.  Seen fairly frequently with associated neuromuscular conditions such as CP, lower motor neuron disease, and myopathic diseases.  Cardiopulmonary impairment occurs when curves exceed 60 degrees.

Classification:  Congenital (birth – 3 years) and juvenile (age 4-10) are convex to the left; idiopathic: convex to the right; can also be secondary to conditions listed above; if pain: abnormal 

Association with other bony abnormalities: MRIs done on those with scoliosis show about a 30% incidence of other problems: most are: < 11 years of age at presentation, have pain, have hyperkyphosis, severe curves, presence of left thoracic or thoracolumbar curves.

Questions you must answer when evaluating teenager for scoliosis:

1. Is one shoulder higher than the other?:  If evident that there is a difference:

• Measure the leg lengths by measuring from anterior iliac crest to medial malleolus; compare one leg length to the other.  Greater than 2 cm difference clearly abnormal. 
• In pelvic tilt: if one anterior iliac crest higher than the other, probably normal tilt.

2. Is there curvature of the spine?  If no evidence of pelvic tilt:

• Look at back of child with child standing with feet together. 
• Make an ink mark over each vertebral process to see if there is a significant curve.
• Do the forward bend test: by having the child bend from the waist, find thoracic rotational deformities or rib humps.  MOST IMPORTANT TEST TO DO ON EXAM!  Often find this abnormal, when no obvious curvature otherwise noted.
• Consider using a scoliometer: hand-held instrument may or may not be helpful.
• If necessary, do an x-ray of the spine, and ask for number of degrees of scoliosis.

3. If scoliosis present, how severe is it? How many degrees of curvature?

• Refer to an orthopedist if >15-20 degrees or has progressed from previous film

4. If pediatrician does not need to refer, how often should child be re-Xray’d? 

• Do repeat exam, and re X-ray every 6 months until stable. 

5. What is the treatment for scoliosis, and when is surgery indicated?

• < 20 degrees in immature, < 30 degrees in mature: follow with no treatment other than observation, follow-up exam and x-ray.
• 25-30 degrees: orthotic therapy: Milwaukee brace, Boston brace; another called the Charleston Bending Brace worn only at night
• Greater than 50 degrees: surgery because of cardiopulmonary compromise.

Written 5/01

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004