Pediatric Spinal Evaluation for Scoliosis and Back Pain
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1 Pediatric Spinal Evaluation for Scoliosis and Back Pain Jill E. Larson, MD September 29, 2018 Ann & Robert H. Lurie Children s Hospital of Chicago Division of Pediatric Orthopedic Surgery and Sports Medicine
2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation. 2
3 Objectives How to perform an efficient but effective clinical evaluation for scoliosis and backpain When to get advanced imaging (MRI) Scoliosis Back Pain When to refer to your friendly Orthopedic Surgeon 3
4 Case #1 TV is a 14 y/o girl who presents for evaluation of spine asymmetry noted by her family. She has mild, intermittent diffuse back pain unrelated to activity. She denies paresthesias, weakness, bowel/bladder dysfunction.
5 History, cont PMH: prior work-up for delayed growth Family history: 16 y/o brother wears brace for scoliosis Birth/development history: unremarkable Premenarchal
6 Refer to Orthopedic Surgery 6
7 Spinal Evaluation Physical Exam Patient should be undressed sufficiently INSPECTION PALPATION RANGE OF MOTION SPECIAL TESTS 7
8 Spinal Evaluation INSPECTION Asymmetries: Neck Shoulders Scapulae Waist Hips (distinguish scoliosis from leg length discrepancy by hands on iliac crests) Look at their skin - Dimples - Hairy patches - Cafe -au-lait spots Look for scoliosis and kyphosis
9 Spinal Evaluation PALPATION Neurologic examination Body habitus tall and lanky? Gait Flexibility pain with flexion/extension Palpation midline and paraspinal Hip motion FABER Abdominal exam and flank percussion 9
10 Spinal Evaluation RANGE OF MOTION Neurologic examination Body habitus tall and lanky? Gait Flexibility pain with flexion/extension Palpation midline and paraspinal Hip motion FABER Abdominal exam and flank percussion 10
11 Physical exam Right thoracic, left lumbar prominence with Adam s forward bending test ATR=6
12 Spinal Evaluation SPECIAL TESTS Congenital scoliosis Spondylolisthesis Tumors Neurofibromatosis Tethered spinal cord Neurologic exam - reflexes, strength Feet - cavus or other deformities? Hamstrings - tight with spondylolisthesis, tumors, Scheurmann s kyphosis
13 Scoliometer, Inclinometer Choose area of greatest asymmetry Center on the spinous processes Estimate rib or lumbar paraspinal muscle hump Angle of trunk rotation - ATR Not the Cobb angle
14
15 Scoliometer Practical, portable, reproducible for follow-up of mild, low risk curves If rib hump ( angle of trunk rotation ) <5 by inclinometer: curve is <20 Cobb on X-ray (>98% probability) (common sense needed)
16 Newer data of Bunnell suggests 7 threshold for cost-effective referral to Orthopedist Author suggests 5º % Students Referred % Curves >20 deg Missed Old Scoliometer Reading - A.T.R. deg. % Screened Patients Referred % Missed Curves > 30 deg. New?
17 Refer to Orthopedic Surgery 17
18 Radiographs - minimize: Standing PA view standard best: long cassette using high speed film to minimize dose breast dose in less in PA vs. AP Order TL Spine
19 Radiographs- Standing Lateral view only if pain, lordosis, kyphosis or needs treatment 2-3X the radiation dose of the PA view. No indication for the scoliosis series (bends, supine AP, etc.) except surgery
20
21 Risser sign
22 Refer to Orthopedic Surgery 22
23 Diagnosis? Adolescent Idiopathic Scoliosis (AIS)
24 Adolescent Idiopathic Scoliosis Disorder of growth/programming 2% prevalence Genetic factors My sister has scoliosis, what is the chance that I will have scoliosis? 11% with affected 1 st degree relative Female predominance (5:1)
25 Differential Diagnosis Non-idiopathic scoliosis Risk factors: Atypical curve Pelvic obliquity Associated exaggerated kyphosis severe or focal pain Associated medical condition Age <10 at presentation Idiopathic scoliosis + another condition causing back pain
26 Ordering an MRI P pain/pelvic obliquity L LEFT thoracic curve A Age/acceleration N Neurologic findings K Kyphosis 26
27 Etiology of Scoliosis: Many possible etiologies: (except congenital) Scoliosis, kyphosis in children probably a common final pathway, with differing expressions of: Neurologic disorder / imbalance Connective tissue susceptibility Genetic predisposition Final Common Pathway Growth Disturbance
28 Classification of Scoliosis: Etiology Idiopathic, Neuromuscular, Congenital Age Infantile, Juvenile (Early Onset), Adolescent (Late Onset), Adult degenerative Curve Direction: Scoliosis, Kyphosis, Hypo- or Hyper-kyphosis, Lordosis Curve Apex: C, CT, T, TL, L Magnitude: Structural or Non-structural Lenke King
29 Infantile Idiopathic Rare, more in northern Europe M=F, L thoracic common Associated with other deformations Some resolve spontaneously Rib-vertebral angle difference (RVAD of Mehta) < 20 predictive of resolution / progression Diagnosis: MRI to r/o neuropathic cause Observation: if RVAD small Treatment Serial casts, Braces, Early growing rod, Fusion
30 Juvenile Idiopathic Scoliosis Juvenile (ages 2-10) mild -? precursor to AIS - observe for progression moderate or progressive (?15-20º?) - Consider screening MRI may be secondary to Chiari I malformation and syringomyelia (~15%) brace if >20º
31 Juvenile Idiopathic Scoliosis High incidence of Chiari I malformation with syrinx Decompression helps with curve management Smaller curves may resolve spontaneously
32 Adolescent Idiopathic Scoliosis Most curves worsen with growth Many curves < 30 may not progress further may spontaneously improve! Risk factors for worsening of curves: Growth remaining Curve magnitude
33 Steady curve progression with growth
34 Rapid curve progression with growth
35 Spontaneous curve improvement
36 Curve progression, then spontaneous improvement
37 AIS: Natural History Curves >50 degrees likely to progress once patient stops growing Average of 1 degree/year >60 degrees, notable decrease in PFT Cardiopulmonary compromise with curves 90+ Slightly higher rates of back pain Montreal study: 73% of individuals with AIS vs 56% of controls had experienced back pain in the past year Mayo et al, Spine, 1994
38 Treatment Depends on skeletal maturity Guidelines <10 degrees: follow with PCP 10-25: observation 25-40: brace >45: consider spinal fusion
39 Case #2 TV is a 14 y/o girl who presents for evaluation of spine asymmetry noted by her family. She has mild, intermittent diffuse back pain unrelated to activity. She denies paresthesias, weakness, bowel/bladder dysfunction.
40 Refer to Orthopedic Surgery 40
41 Back Pain Clinical Evaluation Important History Questions Interference with ADLs or recreation Bowel or bladder symptoms Leg pain, weakness Gynecologic history Unexplained weight loss or weight gain Abnormal bruising 41
42 Back Pain The Good News Factors associated with identifiable cause 1. Male sex 2. Constant Pain 3. Night pain 4. Brief duration of symptoms 42
43 Back Pain the Not So Good News 50% incidence by age 15 Much more common in females 83% in preceding 3 months Exhaustive work up not always indicated Psychosomatic cause rare in children less than 10 *Don t blow off kids < 10 Source of pain found in 22-84% 43
44 Spinal Evaluation Physical Exam Patient should be undressed sufficiently INSPECTION PALPATION RANGE OF MOTION SPECIAL TESTS 44
45 Complete Physical Exam 45
46 Back Pain Work-up Plain radiographs Not always necessary with activity related back pain in children > 10 Yes if patient < 10 years If obtaining XR, should probably include the entire spine and pelvis * Look for subtleties - psoas shadow - disk heights - pedicle shadows 46
47 Refer to Orthopedic Surgery 47
48 Complete Physical Exam 48
49 Refer to Orthopedic Surgery Refer to Neurosurgeon 49
50 Back Pain Differential Diagnosis Musculoskeletal strain Spondylolysis or Spondylolisthesis Discogenic Scoliosis Infection (ie diskitis, osteomyelitis) Intra-spinal pathology (tethered cord, syrinx, chiari) Tumor Benign Osteoid Osteoma, ABC, Langerhans histiocytosis Malignant Leukemia (ALL) - Most common malignant cause of back pain Neuroblastoma - Thoracic spine mets in young children 50
51 Back Pain Differential Diagnosis by Age Patients < 10 - Infection - Neoplasm - Congenital abnormalities Patients > 10 - Fractures - Disc herniation - Overuse injuries - Spondylolysis/listhesis - Deformity (Scheuermann s kyphosis) - Neoplasms 51
52 Refer to Orthopedic Surgery 52
53 The Backpack Question Review of literature suggested 15-20% of body weight as maximum - Mackenzie et al. Clin Orthop Relat Res 2003; 409: 78 53
54 Changes You May Want to Make to Your Practice 1. Obtain a scoliometer (ATR) reading on all children age >10 years of age Refer to Orthopedic surgeon when ATR > 7 degrees 2. Reduce XR exposure by only obtaining an PA TL spine radiograph unless pain, lordosis/kyphosis noted on exam, then consider lateral image 3. Implement a back pain algorithm with appropriate referral to Orthopedic surgery 54
55 Thank you!
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