Pediatric orthopedic cases 39
CASE 39
Dr. Coleen S. Sabatini
A 12-year-old, premenarchal girl has been referred to you by her pediatrician after school screening for scoliosis raised concern. On examination, she has a left thoracolumbar prominence on Adam’s forward bend test. She has normal, symmetrical reflexes. Her motor and sensory examinations are normal as well. She has no pain and no complaints at this time. Her standing spine film is as follows (Fig. 10–66):
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Figure 10–66
You measure the Cobb Angle and obtain a value of 18 degrees. She is Risser 0. Her lateral x-ray shows hypokyphosis of the thoracic spine and no spondylolysis/spondylolisthesis. What do you recommend for treatment at this time?
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Observation
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MRI of the spine
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Boston brace
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Posterior spine instrumentation and fusion
Discussion
The correct answer is (A). This is a healthy, 12-year old who is premenarchal, neurologically normal, with a curve of only 18 degrees. For this patient, you would follow her examination and radiographs over time to see if there is progression. B
—hand film for bone age—is not needed at this time because her curve magnitude is not large enough to consider interventions for which knowing more about her skeletal maturity is necessary. C is not correct because she has a classic presentation for adolescent idiopathic scoliosis, and there is not anything in her history nor examination that would suggest the need for MRI. If she had an abnormal neurologic examination or red flags on history, then an MRI would be warranted. D is incorrect because a curve of 18 degrees does not warrant brace treatment. Curves greater than 25 degrees in patients who are still growing are candidates for bracing (Risser 0, 1, 2). E is incorrect because a curve of 18 degrees is not large enough to warrant surgical intervention—thoracic curves larger than 50 degrees or lumbar curves larger than 45 degrees are the curve magnitudes for which you would consider surgery (although smaller curves in the setting of significant decompensation or underlying conditions would also be considered, but that is not the case here).
A 13-year-old girl is next in your clinic. This patient is 2 months postmenarchal. She was recently seen by a pediatrician for the first time in about 4 years just last week, and her new pediatrician was very concerned given notable asymmetry on forward bend testing. She ordered an x-ray (Fig. 10–67) and referred her to you when she saw the following:
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Figure 10–67
On examination, she has a notable right thoracic prominence on Adam’s forward bend test. She has normal reflexes, normal strength, and normal sensation on examination. You measure her x-ray and note that she has a right thoracic curve that measures 56 degrees. She is Risser 1 on examination.
What do you recommend to the family?
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Observation
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MRI of the spine
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Boston brace
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Posterior spine instrumentation and fusion
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Combined anterior and posterior fusion with posterior instrumentation
Discussion
The correct answer is (D). The curve magnitude is over 50 degrees and menarche was in the last few months, therefore she still has growth left—both of these put her at risk of curve progression over time. Spinal fusion is recommended for patients with curves larger than 50 degrees, as this patient has. A and C are incorrect. Her curve is past the point where a brace can be helpful—curves larger than 40 degrees do not respond well to bracing. An MRI is not needed because this is an adolescent onset curve, no red flags on history, and there are no neurologic findings. With modern surgical techniques and instrumentation, a combined anterior/posterior surgery is not needed in this patient as her curve is less than 75 degrees and she has no associated syndromes. For curves larger than 75 to 80 degrees, one may consider doing a combined anterior/posterior procedure or if the curve is particularly stiff as well. Excellent results can be obtained from a posterior fusion with instrumentation.
You go next to see a patient who is 13 years old and had spine asymmetry picked up on school screening. Her pediatrician saw her last year and obtained an x-ray that showed a curve of 17 degrees. At one year follow up with the pediatrician, it was found that the curve had progressed. Parents as well as the patient report occasional diffuse back pain without radiation, no weakness in the arms or legs. She functions well in PE and sports with no difficulties. She is premenarchal. Her examination is notable for an apex right thoracic prominence and an apex left lumbar prominence on Adam’s forward bend test. Examination is otherwise normal. You review her xray (Fig. 10–68).
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Figure 10–68
Given that she has a curve greater than 25 degrees and is still growing (premenarchal, Risser 0), you offer the patient a Boston brace for treatment of her scoliosis. What do you tell them about wearing the brace in order to help make it as effective as possible?
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She should wear the brace just at night.
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She should wear the brace for at least 8 hours a day during the daytime.
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She should wear the brace for 18 to 20 hours a day with at least 12 hours in the daytime.
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She should wear the brace at all times on weekends, but can wear on the weekdays just at night.
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Wearing a brace probably won’t help, but she can try it anyway.
Discussion
The correct answer is (C). Although it is true that earlier studies about bracing were not very conclusive as to whether or not bracing was helpful in the treatment of adolescent idiopathic scoliosis, earlier studies were flawed by having inaccurate data with regard to the amount of time patients were actually wearing the brace. Recent studies (Katz, Weinstein) have utilized temperature sensors in braces to get a true measurement of brace wear. These studies showed a dose-response relationship between amount of time in brace with prevention of progression of curve—within that, they found that brace wear for 12 or more hours during the daytime was most effective in preventing curve progression. Thus, of the options provided above, C is the best answer since it has the patient in the brace for at least 12 hours of daytime wear. A, B, and D are not enough time in the brace to benefit. E is incorrect based on these new studies—particularly given that this patient is Risser 0.
Objectives: Did you learn...?
The evaluation of patients with scoliosis in adolescence?
The curve magnitude indications for observation versus bracing versus surgery?
The indications for brace treatment and the necessary time in brace to have potential benefit?