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 Know how to perform an efficient but effective clinical evaluation for scoliosis and backpain Be educated on when to order advanced imaging (MRI) Scoliosis Back Pain Know the algorithm for when to refer a patient to your friendly Orthopedic Surgeon 3

4 Case #1 TV is a 14 y/o girl who presents for evaluation of spinal 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: exercise induced asthma Family history: 16 y/o brother wears brace for scoliosis Birth/development history: unremarkable Premenarchal

6 Spinal Asymmetry 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 Body habitus tall and lanky?

9 Spinal Evaluation PALPATION Palpation midline and paraspinal Note any abnormal step-offs of the posterior spinous processes Abdominal exam and flank percussion 9

10 Spinal Evaluation RANGE OF MOTION Adam s Forward Bend Test Flexibility pain with flexion/extension Spinal rotation Hip motion FABER Neurologic examination - reflexes, strength Gait 10

11 Physical exam Right thoracic, left lumbar prominence with Adam s forward bending test ATR=10

12 Spinal Evaluation SPECIAL TESTS 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 % Students Referred % Curves >20 deg Missed Old Scoliometer Reading - A.T.R. deg. % Screened Patients Referred % Missed Curves > 30 deg. New?

17 Spinal Asymmetry 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 for surgical planning

20

21 Spinal Asymmetry Refer to Orthopedic Surgery 21

22 Diagnosis? Adolescent Idiopathic Scoliosis (AIS)

23 Adolescent Idiopathic Scoliosis Disorder of growth/programming 2% prevalence Genetic component My brother has scoliosis, what is the chance that I will have scoliosis? 11% with affected 1 st degree relative Female predominance (5:1)

24 Differential Diagnosis Non-idiopathic scoliosis Risk factors: Atypical curve Refer to Orthopedic Surgery Pelvic obliquity Associated exaggerated kyphosis severe or focal pain Associated medical condition Age <10 at presentation Idiopathic scoliosis + another condition causing back pain

25 Ordering an MRI P L A N K pain/pelvic obliquity LEFT thoracic curve Age/acceleration Neurologic findings Kyphosis 25

26 Etiology of Scoliosis: Many possible etiologies: (except congenital) Scoliosis in children is probably a common final pathway, with differing expressions of: Neurologic disorder / imbalance Connective tissue susceptibility Genetic predisposition Final Common Pathway Growth Disturbance

27 Infantile Idiopathic Diagnosis < 2 years of age Rare, more in northern Europe M=F, L thoracic common Associated with other deformations Some resolve spontaneously Refer to Orthopedic Surgery 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

28 Juvenile Idiopathic Scoliosis Juvenile (ages 2-10) Refer to Orthopedic Surgery 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

29 Juvenile Idiopathic Scoliosis High incidence of Chiari I malformation with syrinx Decompression helps with curve management Smaller curves may resolve spontaneously

30 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 Refer to Orthopedic Surgery

31 Steady curve progression with growth

32 Rapid curve progression with growth

33 Spontaneous curve improvement

34 Curve progression, then spontaneous improvement

35 AIS: Natural History Refer to Orthopedic Surgery 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

36 Treatment Depends on skeletal maturity Guidelines <10 degrees: follow with PCP 10-25: observation 25-40: brace >45: consider spinal fusion

37 Case #2 TV is a 14 y/o girl who presents for evaluation of spinal asymmetry noted by her family. She has mild, intermittent diffuse back pain unrelated to activity. She denies paresthesias, weakness, bowel/bladder dysfunction.

38 Refer to Orthopedic Surgery 38

39 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 39

40 Back Pain The Good News Factors associated with identifiable cause 1. Male sex 2. Constant Pain 3. Night pain 4. Brief duration of symptoms 40

41 Back Pain the Not So Good News 50% incidence by age 15 Much more common in females 83% of patient have had in the preceding 3 months Exhaustive work up not always indicated Psychosomatic cause rare in children less than 10 so don t blow off kids < 10 Source of pain found in 22-84% 41

42 Spinal Evaluation Physical Exam Patient should be undressed sufficiently INSPECTION PALPATION RANGE OF MOTION SPECIAL TESTS 42

43 Complete Physical Exam 43

44 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 44

45 Refer to Orthopedic Surgery 45

46 Complete Physical Exam 46

47 Refer to Orthopedic Surgery Refer to Neurosurgeon 47

48 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 48

49 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 49

50 Refer to Orthopedic Surgery 50

51 The Backpack Question Review of literature suggested 15-20% of body weight as maximum - Mackenzie et al. Clin Orthop Relat Res 2003; 409: 78 51

52 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 MRI order and referral to Orthopedic surgery 52

53 Thank you!

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