Disorders of Spinal Growth and Development Malposition of the head and neck with lateral flexion to one side and rotation to the contralateral side. The child holds the ear closer to one shoulder and the chin closer to the other. Muscular torticollis resulting from contracture of sternocleidomastoid. Atlantoaxial rotatory instability. Congenital bony malformation of upper cervical spine. Reflux response (Sandifer syndrome). Ocular or auditory abnormality. Brainstem abnormality or tumor. Measure range of motion to each side. Thorough neurologic examination. Palpate for sternocleidomastoid contracture (typically tight on the side of the lower ear). Examine eye movements and hearing. Plagiocephaly is a sign of early onset, longer duration. Plain films centered on upper cervical spine: Usually difficult to interpret because of rotation. Include anteroposterior open mouth view if possible. CT with reconstructions usually necessary when treatment is needed. MRI if neurologic abnormality is suspected or if surgery is planned. Muscular torticollis: Stretching, possible lengthening. Atlantoaxial rotatory instability: Stretching if duration less than 1 week; traction if 1 to 3 weeks; fusion if over 1 to 3 months. Idiopathic scoliosis is the most common pediatric spinal deformity. It is transmitted as an autosomal dominant condition with incomplete penetrance. The initial evaluation should rule out other causes and determine maturity, curve size, type, and appropriate treatment. Infantile scoliosis (onset 0–3 years): obtain MRI. Juvenile scoliosis (onset 4–9 years): obtain MRI. Adolescent scoliosis (onset >9 years): routine MRI not indicated. How curve was discovered. Presence or absence of significant pain. Family history. Menarchal status. Medical and surgical history. Record height and weight. Assess trunk and extremities for cutaneous lesions, congenital malformation, connective tissue disorder, or atrophy. Measure pelvic height for inequality of lower-limb length. Neurologic examination: Strength, reflexes all extremities. Abdominal reflex testing. Estimate physical maturity (breast appearance, facial or axillary hair). Assess curve: Shoulder elevation. Trunk balance C1 through S1, coronal and sagittal. Curve level. Intrinsic pelvic deformity. Kyphosis and lordosis. Genetic or connective tissue: Marfan syndrome, Loeys–Dietz syndrome. Ehlers–Danlos syndrome. Neurofibromatosis. Prader–Willi syndrome. Stickler syndrome. Many others. Neurologic: Syringomyelia. Brainstem or cord tumor. Friedreich ataxia. Charcot–Marie–Tooth disease. Polio Thoracic-level paralysis or dyscoordination of any cause. Neoplastic and other: Tethered cord/occult dysraphism. Osteoid osteoma. Osteoblastoma. Postradiation. Spinal cord tumor. Fig. 3.1 (a-d) Forward-bending test for spinal deformity. Patient stands with feet together, knees straight, palms together. Check shoulders and pelvis for obliquity, and equalize leg lengths with blocks if necessary. Observe sagittal profile for focal kyphosis. Have patient bend slowly all the way over. Check thoracic spine. Check lumbar spine. Scoliometer measurement of trunk asymmetry (▶ Fig. 3.2). It measures the angle of trunk rotation. This is roughly coordinated with the Cobb angle. A scoliometer reading of 5 or less is 99% sensitive and 97% specific for curves less than a 20-degree Cobb angle. The mean Cobb measurement for curves 5 degrees by scoliometer is 11 degrees. A scoliometer reading of 7 or less is 88% sensitive and 86% specific for curves less than 25 degrees with a mean Cobb of 20 degrees. The scoliometer is adequately sensitive for scoliosis screening: 95% of curves greater than 20 degrees measure 7 degrees or more on the scoliometer. Obesity may mask significant scoliosis, however. Fig. 3.2 Technique of scoliometer measurement. (Used with permission from Bunnell WP. An objective criterion for scoliosis screening. J Bone Joint Surg Am 1984;66(9):1383 (Fig. 3).) Bibliography 1. Bunnell WP. Outcome of spinal screening. Spine 1993;18(12):1572–1580 2. Margalit A, McKean G, Constantine A, Thompson CB, Lee RJ, Sponseller PD. Body mass hides the curve: thoracic scoliometer readings vary by body mass index value. J Pediatr Orthop 2017;37(4):e255–e260 A radiograph should be made if the physical examination indicates that a curve may require treatment. Posteroanterior technique minimizes dose to gonads and breast but gives slightly less detail. A lateral film should be ordered only if needed for evaluation of pain or sagittal deformity. The EOS slot-scanner provides the lowest dose. Look for other anomalies, such as congenital malformation, vertebral erosion, or pedicle widening or thinning. The curve magnitude may be described by the Cobb measurement (▶ Fig. 3.3) and the direction of convexity and levels involved. The interobserver measurement error (Cobb) is around 5 degrees for idiopathic scoliosis and greater than 10 degrees for congenital scoliosis. Skeletal maturity may be roughly estimated by the Risser sign but should be correlated with physical examination (Tanner) and bone age if needed (see Chapter 1 [Fig. 1.12 and Fig. 1.18]). Rotation in the adolescent may be estimated by the method of Nash and Moe (▶ Fig. 3.4) or by CT or the Perdriolle method. Rotation may be estimated in the infantile or juvenile patient using the ribvertebra angle difference (RVAD) of Mehta (▶ Fig. 3.5). Curve types are named for the level of the apex: Thoracolumbar curves have an apex at or between T12 and L1. Thoracic curves have an apex above this. Lumbar curves have an apex below this. The Lenke classification of curve types is more comprehensive and incorporates sagittal characteristics (▶ Fig. 3.6). Main thoracic. Double thoracic. Double major. Triple major. Thoracolumbar/lumbar. Thoracolumbar/lumbar: Main thoracic. Fig. 3.3 Cobb method of measurement. The angle between the upper and lower end vertebrae (EV) in the curve. Risser sign reflects maturation of the ilium. Grade 5 is fused epiphyses. It has a rough correlation with skeletal age and helps predict the end of skeletal growth. It should not be used in isolation. The stable vertebra is the lowest vertebra bisected by a vertical line from the center of the sacrum. The apical vertebral translation is measured with respect to the central sacral line.
3.1 Torticollis
3.1.1 Differential Diagnosis
3.1.2 Physical Examination and Findings
3.1.3 Imaging
3.1.4 Treatment
3.2 Idiopathic Scoliosis
3.2.1 History
3.2.2 Physical Findings and Examination
3.2.3 Differential Diagnosis (in Absence of Overt Vertebral Malformations)
3.2.4 Scoliosis Screening: Forward-Bend Test (▶ Fig. 3.1)
3.2.5 Imaging
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
