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
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
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
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.
History, cont PMH: exercise induced asthma Family history: 16 y/o brother wears brace for scoliosis Birth/development history: unremarkable Premenarchal
Spinal Asymmetry Refer to Orthopedic Surgery 6
Spinal Evaluation Physical Exam Patient should be undressed sufficiently INSPECTION PALPATION RANGE OF MOTION SPECIAL TESTS 7
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?
Spinal Evaluation PALPATION Palpation midline and paraspinal Note any abnormal step-offs of the posterior spinous processes Abdominal exam and flank percussion 9
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
Physical exam Right thoracic, left lumbar prominence with Adam s forward bending test ATR=10
Spinal Evaluation SPECIAL TESTS Feet - cavus or other deformities? Hamstrings - tight with spondylolisthesis, tumors, Scheurmann s kyphosis
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
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)
Newer data of Bunnell suggests 7 threshold for cost-effective referral to Orthopedist % Students Referred % Curves >20 deg Missed 100 80 60 40 20 0 Old 1 2 3 4 5 6 7 8 9 10 Scoliometer Reading - A.T.R. deg. % Screened Patients Referred % Missed Curves > 30 deg. New?
Spinal Asymmetry Refer to Orthopedic Surgery 17
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
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
Spinal Asymmetry Refer to Orthopedic Surgery 21
Diagnosis? Adolescent Idiopathic Scoliosis (AIS)
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)
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
Ordering an MRI P L A N K pain/pelvic obliquity LEFT thoracic curve Age/acceleration Neurologic findings Kyphosis 25
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
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
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
Juvenile Idiopathic Scoliosis High incidence of Chiari I malformation with syrinx Decompression helps with curve management Smaller curves may resolve spontaneously
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
Steady curve progression with growth
Rapid curve progression with growth
Spontaneous curve improvement
Curve progression, then spontaneous improvement
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
Treatment Depends on skeletal maturity Guidelines <10 degrees: follow with PCP 10-25: observation 25-40: brace >45: consider spinal fusion
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.
Refer to Orthopedic Surgery 38
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
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
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
Spinal Evaluation Physical Exam Patient should be undressed sufficiently INSPECTION PALPATION RANGE OF MOTION SPECIAL TESTS 42
Complete Physical Exam 43
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
Refer to Orthopedic Surgery 45
Complete Physical Exam 46
Refer to Orthopedic Surgery Refer to Neurosurgeon 47
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
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
Refer to Orthopedic Surgery 50
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
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
Thank you!