Scoliosis and Kyphosis

Abstract

Scoliosis is a three-dimensional deformity of the spine and the trunk; it associates a spinal pathologic curve on the frontal plane, a rotation in the horizontal plane, and a disturbance of the normal curves on the sagittal plane. Idiopathic scoliosis is the most common form (85% to 90%). Adult spinal deformity is defined when scoliosis is diagnosed after skeletal maturity. Sagittal plane alterations affect sagittal spinal curves in terms of both quantity and distribution. These conditions can be idiopathic, due to Scheuermann disease, or secondary to other diseases. The clinical evaluation of patients is based on a morphologic analysis and surface measures. The pathognomonic sign of scoliosis is the presence of a hump noted on forward bending test and can be measured with a Bunnell scoliometer. The plumbline is used to assess the sagittal and frontal profiles. Standing frontal and lateral full spine x-rays are the gold standard to identify spinal deformities, to assess the scoliotic and sagittal curves, to assess skeletal maturity, and monitor progression and treatments results, but also to rule out any underlying conditions. According to the SOSORT guidelines, goals of scoliosis treatment are morphologic and functional; they include improvement of aesthetics, reduction of curve progression at puberty, and prevention of spinal pain syndromes and respiratory dysfunction. Goals of treatment for kyphosis include curve correction, spine alignment recovery, and pain alleviation. Treatment is based on specific exercises, braces of different material (elastic, rigid, very rigid), and/or surgery according to the gravity of the scoliosis/kyphosis and the risk of progression.

Keywords

Braces, kyphosis, lordosis, sagittal balance, scoliosis, therapeutic exercises

Synonyms
Scoliosis Curvature of the spine/back Curved spine/back Kyphosis Hunchback Humpback Roundback Dorsum rotundum Dowager’s hump Postural kyphosis Gibbus deformity
ICD-10 Codes
Scoliosis
41.1	Juvenile and adolescent idiopathic scoliosis
41.12	Adolescent scoliosis
41.2	Other idiopathic scoliosis
41.3	Thoracogenic scoliosis
41.4	Neuromuscular scoliosis
41.5	Other secondary scoliosis
41.8	Other forms of scoliosis
41.9	Scoliosis unspecified
Kyphosis
40.0	Postural kyphosis
40.1	Other secondary kyphosis
40.2	Other and unspecified kyphosis
40.29	Other kyphosis

Definitions

Scoliosis

Scoliosis is a three-dimensional deformity of the spine and the trunk ; it associates a spinal pathologic curve on the frontal plane (curves of 10 degrees or more must be present to diagnose the disease), a rotation in the horizontal plane, and a disturbance of the normal curves on the sagittal plane (often in terms of flat back and hollow back). Idiopathic scoliosis (IS) is the most common form (85% to 90%) and is diagnosed when a specific etiology is not identified ; the accepted classifications for idiopathic scoliosis during growth are listed in Table 153.1 . Secondary scoliosis is a feature of different pathologic processes including neurologic diseases, systemic syndromes, connective tissue disorders, tumors, or trauma.

Table 153.1

Classifications of Idiopathic Scoliosis During Growth

Chronological		Angular			Topographic
Age at diagnosis (years.months)		Cobb degrees				Apex
						From	To
Infantile	0–2.11	Low	Low	20 or less	Cervical	–	Disc C6-7
Juvenile	3–9.11	Moderate	Moderate	21–35	Cervicothoracic	C7	T1
Adolescent	10–17.11		Moderate to severe	36–40	Thoracic	Disc T1-2	Disc T11-12
Adult	18+	Severe	Severe	41–50	Thoracolumbar	T12	L1
			Severe to very severe	51–55	Lumbar	Disc L1-2	–
		Very severe		56 or more

See references [ , ⁴¹].

Adult spinal deformity (ASD) is defined when scoliosis is diagnosed after skeletal maturity. Scoliotic curves identified during adulthood can be developed prior to skeletal maturity, after skeletal maturity, or after surgery or trauma. Currently three classification systems based on the etiology, on the clinical impact of the deformity, and on curve types and additional modifiers have been developed for ASD: Aebi, Schwab, and SRS. The last two were combined recently into a single classification.

Kyphosis

Kyphosis is a physiologic thoracic anterior concave spinal curvature in the sagittal plane, associated with cervical and lumbar lordosis in a physiologic conformation of the spine. Physiologic values for kyphosis during growth are between 20 to 25 degrees and 40 to 45 degrees. Sagittal plane alterations affect sagittal spinal curves in terms of both quantity and distribution. Thus, hyperkyphosis (HK), which is defined as an increase of the kyphosis, can be distinguished between high thoracic, thoracic, thoracolumbar, and lumbar HK according to the level where the apex of the curve can be identified. Concerning the sagittal spinal profile, it is also important to distinguish alterations such as long kyphosis, normal kyphosis with a caudal vertebra below T12, and junctional kyphosis, flat back with distal kyphosis with caudal vertebrae below T12. An association between scoliosis and one of these sagittal deformities is possible ( Fig. 153.1 ).

These conditions can be idiopathic or secondary to Scheuermann disease (a disease disturbing vertebral growth) or secondary to reduced trunk extensor muscle weakness or neurologic problems, congenital vertebral dysmorphic syndromes, trauma, tumors, or advanced degenerative disease of the spine.

Symptoms

Scoliosis

Scoliosis is usually asymptomatic during adolescence and generally trunk asymmetries are signs that first bring the patients to the physician. Rarely, patients report low back pain and respiratory dysfunction. The latter is especially linked to large curvatures of the thoracic spine, but data from long-term follow-up studies suggest that cardiorespiratory symptoms are not common in adults with adolescent idiopathic scoliosis and occur only in cases of severe scoliosis that had its onset in pre-puberty and with a strong tendency to progression.

Adults affected by scoliosis report more symptoms than adolescents because of the addition of spinal degenerative processes and worsening of the sagittal alignment. The most frequently reported symptoms are low back pain that typically increases in orthostasis and is located at the hump, stiffness, fatigue, cramping, and shooting pain in the legs. Recent studies underline the influence of symptoms’ perception on treatment decisions. Patients with worse patient-reported outcomes, more back pain, more back and leg pain with ambulation, and larger lumbar Cobb angles are more inclined to select surgical over nonsurgical management.

Kyphosis

Patients with sagittal malalignment can be asymptomatic and often the round back is the only alarm bell for patients and their parents. Sometimes the deformity is associated with back pain that has mechanical features related to movement and posture. Backache can affect adolescents but even more adults because of the presence of degenerative processes.

Physical Examination

The main goals of the clinical assessment are diagnostic classification, treatment planning, and prediction in terms of prognosis and future functional capacity.

Concerning spinal deformities, potential causes of secondary scoliosis or sagittal malalignment must be investigated during the first visit and it is important to inquire about associated signs and symptoms.

The clinical evaluation of patients both with scoliosis and sagittal malalignment is based on a morphologic analysis based on the surface measures taken by a physician. Some instruments are essential for the examination: a plumbline, a Bunnel scoliometer, a ruler, wooden tablets of progressive thickness (2, 3, 5, 10 mm), a scale, and a height measure.

The patient should be evaluated in standing position, with straight legs and habitual posture. At the side of the patient it is possible to evaluate the ante/retroversion of the pelvis, the abdominal prominence, the ante/retroposition of the trunk, and the anteposition of the head. Especially in adults, pelvic retroversion and hip and knee flexion are compensatory measures of positive sagittal malalignment and should be recorded in the physical exam. Frontally it is possible to evaluate rib cage abnormalities such as pectus excavatum or carinatum. From the back the symmetry of the trunk and head position can be evaluated and prominence of the spinous processes can add information concerning the sagittal profile. Aesthetics is considered a major goal of conservative scoliosis treatment by the International Scientific Society on Scoliosis Orthopedic and Rehabilitation Treatment SOSORT experts and one of the most relevant indications for surgery. Recently a clinical scale for objective aesthetic evaluation has been developed, the “Trunk Aesthetic Clinical Evaluation” (TRACE). It is based on four sub-scales: shoulders (0 to 3), scapulae (0 to 2), hemithorax (0 to 2), and waist (0 to 4). Each point is fully described and gives an ordinal scale for increasing asymmetry.

The evaluation of leg-length discrepancy is useful because it may be a negative influence on the position of the pelvis and lead to frontal imbalance. The discrepancy can be measured by placing blocks of known height under the short limb in orthostasis.

The pathognomonic sign of scoliosis is the presence of a hump noted on forward bending test. This test allows the measurement of the angle of trunk rotation (ATR) with a dedicated instrument called a scoliometer. The instrument is placed on the back and used to measure the most leaning point of each hump. Moving the scoliometer to 0 degree, it is also possible to measure the height of the hump (HH) with a ruler. The ATR and HH correlate with the Cobb angle.

Curve rigidity adds information relevant to the prognosis and therapeutic choices. It can be tested with the patient in the forward bending position and asking the patient to side-bend on one side and then the other. If the curve is flexible, it is possible to invert the hump; if it does not change, the curve is very rigid and structural in nature.

The plumbline is used to assess the sagittal and frontal profiles of the spine. It has been shown to be reliable for intraobserver evaluation. To check the frontal offset, the plumbline is set along the medial sacral crest, and the discrepancy from the plumbline is measured at C7. Considering the sagittal profile, the distance from the plumbline is measured at the spinous processes of C7 and L3 with respect to the most prominent point of the dorsal kyphosis. For the evaluation of kyphosis, the sagittal index is given by C7+L3, and for lordosis L3 distance is used.

The neurologic examination should test for motor function, sensory function, balance, and reflexes (including abdominal and pathologic reflexes such as Babinski). Ambulation should also be evaluated. The evaluation of spinal rigidity in extension is performed in prone position and is crucial to evaluate in hyperkyphotic patients.

Finally, height and weight measurements (with triponderal mass index and body mass index calculations) are important to monitor growth rate and its correlation with the risk of scoliosis progression.

The most widely used tools to measure changes in health-related quality of life and the response to treatment are the SRS-22, the Bad Sobernheim Stress Questionnaire (BSSQbrace), the Brace Questionnaire (BrQ), and the Oswestry Disability Index (ODI); the SRS-7 and ISYQOL are recently developed.

Functional Limitations

During growth, functional limitations related to scoliosis and kyphosis are rarely reported; only in cases of severe deformity can a reduction of spinal motion be found. This is different in adulthood when stiffness is increased by spinal degenerative processes. In adults, curve progression (when scoliosis increases to more than overcome 30 degrees Cobb) and worsening of the sagittal alignment can occur. Moreover, when the deformity is severe and compromises cardiopulmonary function, endurance decreases. Positive sagittal balance has been considered the most reliable predictor of clinical symptoms. Kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine, recognizing sagittal malalignment as a primary determinant of pain and disability in ASD population. As SOSORT guidelines underline, one of the most important reasons we must treat scoliosis during growth is the risk for back pain in adult life.

Only gold members can continue reading. Log In or Register to continue