Sunday, April 17, 2011
Scoliosis
This week you will read an article called "Scoliosis Imaging: What Radiologist Should Know". If you have seen a patient for scoliosis which of the various types of scoliosis did they have? Which radiographic views were, or should have been taken for the given type? If you have yet to see a patient with scoliosis, what did you learn from this article that will help you when you evaluate back patients in the future?
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I saw a patient in her 40's with a double major left thoracic, right lumbar scoliosis. Her curves were somewhere in the upper 40-50 degree range. I was very surprised to hear that growing up she never really treated her scoliosis using bracing or having surgeries, even though her father was a doctor. She had a standing AP view taken to show the scoliosis. I did learn in this article that in cases with a complex osseous deformity, radiography alone is inadequate. Use of CT is mandatory, especially when surgery is planned. MR imaging is used with increasing frequency to evaluate patients with an unusual curve pattern or alarming clinical manifestations. I do know that the treatments she responded best to were stretching of the paraspinals that were tight, and strengthening of the core/back and LE's. She really noticed relief with incorporation of a lot of dynamic stretching and exercises, including dynamic nerve glides.
ReplyDeleteI thought that this article was great at explaining scoliosis and the various imaging methods utilized. I have not yet seen a patient with scoliosis in the clinic. I think that this article has helped me to better understand how the decision of idiopathic vs. congenital scoliosis is determined. Because I will be working primarily with geriatric patients in an inpatient rehab setting, it’s not likely that I’ll be seeing patients for the diagnosis of scoliosis very often. However, it is possible that I could see adult idiopathic scoliosis or some form of secondary scoliosis following surgery. It is helpful knowing the categories of secondary scoliosis. I also thought that table 3 and 4, where they list the indications for further imaging and MRI are something that will be nice to have on hand in case there is a patient that presents with some of the criteria that the doctor or radiologist doesn’t catch.
ReplyDeleteThe most recent patient I have seen with the diagnosis of scoliosis and treated was an adolescent female. She had an idiopathic R thoracic and compensatory L lumbar curve. Her primary curve measured approximately 20 degrees and was referred to PT for R thoracic and R hip pain. The diagnosis was made by a standard AP radiograph. She was not being braced at the time and her curve was just being monitored. Provoking the pain was the patient's active and consuming involvement with band. She played the bass clarinet and demonstrated some postural issues, reported increased pain after band competitions. Therapy consisted of stretching of QL, paraspinals, hip musculature, and strengthening for core/back/scapular stabilization. Also focused on heavily was posture correction.
ReplyDeleteI realize the Cobb angle is a great measurement tool for scoliosis. I thought this article was interesting in pointing out the caveats of the Cobb method. figured there was some intra and definitely inter-rater reliability issues with this but the article pointed out some facts I was unaware of. A decrease in Cobb angle may occur during surgery while prone and under anesthesia that may have a rebound effect once standing. Also, due to vertebral rotation a frontal plane view might not be completely accurate at measuring the Cobb angle and could actually be 20% greater. Thus stressing the importance of maintaining the same position for every measurement.
I recently worked with a 12 year old patient who was diagnosed with neuromuscular myopathic scoliosis with spinal muscle atrophy. She had a 120 degree right thoracolumbar curve. Images taken were an AP view and lateral view in sitting. The scoliosis was treated with a spinal fusion from T2-L4 several months prior to my rotation. A CT scan was also performed prior to the surgery. Due to the spinal muscle atrophy, her treatment was limited. She had never ambulated independently and a power wheelchair was used for her primary form of mobility. Prior to the surgery, she was able to crawl some in her home. Following the surgery, she demonstrated a significant loss of strength in her lower extremities and she was unable to crawl. Physical therapy focused on improving sitting balance as well as increasing LE strength.
ReplyDeleteI thought that this article described the measurement and assessment of the curves very well. Also, the controversy on imaging was very insightful. It was interesting to know that MR imaging is so controversial and is primarily used when alarming clinical manifestations are present. I think that the information regarding various types of imaging will be beneficial when providing education to our patients.
I have not seen a patient with scoliosis in the clinic yet. I did not realize that MR imaging is usually only done when a neurological cause is suspected due to the fact that intramedullary lesions can occur in scoliosis without ever producing symptoms and that genuine idiopathic scoliosis does not normally cause pain. This information is eye opening. I would not believe that the idiopathic curves presented in the x-rays in this article were not painful to the patient. This information will be helpful in my future career, especially if I run into someone with a curve that is painful, I will know to refer them back to their doctor.
ReplyDeleteI know plenty of people with a scoliosis, but I haven't actually treated a patient with the diagnosis. Scoliosis always makes me have to stop and think about if the spine bends one way, it will also include twisting of a sort. This article explains, in great detail, how to look at the scoliosis in a 3 demensional view, and not to solely concentrate on only the frontal plane of the pathology. Along with this, this article has a good section on the biomechanics of scoliosis in young people and how is slows progression of boney growth. This article really makes you have to read one sentence at a time.
ReplyDeleteI actually saw the same patient as Ashley but a few months later at the same clinic. As she said, she had a L thoracic, R lumbar double major curve. She brought in her x-rays, which as Ashley mentioned were standing AP, for me to see and I was astonished at the large degree of her curves. I wouldn't have expected that after having observed her in the clinic and looking at her posture. Something that I learned from the article (or maybe re-learned. Can't remember if Mike mentioned it) is that the abnormal curvatures are initiated by vertebral rotation. I obviously knew this was a component of scoliosis but was unaware that this is what possibly begins the whole process. I agree with Jarod that this article was awesome for explaining that you should take multiple angles and imaging techniques to assess scoliosis. All I've ever seen are AP radiographs but from now on I will keep my eye out for other forms of imaging such as MRI's and CT's.
ReplyDeleteI had a patient who was in her sixties and had been diagnosed with severe adolescent idiopathic scoliosis when she was younger. In her late twenties, she underwent a fusion surgery (T3-L2) to help correct the spinal deformity and reduce the risk of further progression of the curve. When I saw her in the clinic for PT, she was coming secondary to increased pain and muscle tightness of the posterior aspect of her mid-thorax. Numerous standing AP radiographic views had been taken of her spinal curve throughout the years. I had the opportunity to view the differences between her pre-surgical views (when the curve was at its worst), immediately post-surgical, and multiple years after her surgery. It was very interesting to view the differences between these views especially with the amount of spinal fusion that was present after the surgery.
ReplyDeleteThis article did a great job of describing the Cobb angle, which can be inferred from viewing the AP radiograph to determine the progression of the scoliotic curve and the Nash-Moe method which is used to help grade the amount of rotation of the vertebrae. I do not remember learning about the Nash-Moe method in class (sorry if I was not listening that day), thus I enjoyed learning about this particular measurement that I did not even know existed.
I was interested in the process of progression of the curvature with scoliosis. The compression exerted on the vertebral growth plates at the concave side of the curvature causes growth to slow, while traction exerted on the growth plates at the convex side of the cruvature causes growth to accelerate. This is a vicious cycle that drives the progression and is spurred on with rapid growth spurts. This information reminded me of a patient that I didn't acutally treat, but was familiar with during one of my rotations. She was in her 30's with idiopathic scoliosis which had been treated with a fusion and rods in her late teens. However, the rods broke but she decided not to have surgery to repair the rods even though she was having low back pain. This article mentioned that the Cobb angle has limitations but is still the main standard for diagnosis and analysis of scoliosis. Two points stood out to me; the actual Cobb angle might be 20% greater due to difficulty positioning the patient to obtain an accurate frontal view and the post operative rebound effect with loss of correction when the patient returns to standing position. Both of these limitations could have contributed to my patient's surgical failure.
ReplyDeleteI had an 86 year old male patient on my last clinical, I was seeing him for HA's but it was mainly posture related. He had a double curve scoliosis. Left thoracic/Right lumbar and the patient stated he's had it all his life, idiopathic. He was very kyphotic with rib humb on left. No recent images were taken but if they were the best images would be to take more than just at AP because of the rotational component. It would be best to have a 3 dimensional view. At least take AP and lateral radiographs and a CT or MRI would be great too. Due to this patients age though there's not much one can do since he's had it all his life and he is not a surgery candidate to do other health issues.
ReplyDeleteI was really impressed with the 3D imaging of the spine. You can get so much of a better idea of what actual curvature and rotation is going on than with standard images. It was also interesting to know that a referral back to the doctor may be warranted with the indications on Table 4. This article reinforced the notion that skeletal maturity and speed of progression play a huge role in the treatment of these patients. In that regard, it would be important to take an excellent patient history. If the patient has reached skeletal maturity, then there is no reason to brace them. This article also explained the measurement and classification systems well.
ReplyDeletePatients I treated with scoliosis were all during my pediatric rotation and mostly neuropathic scoliosis from acquired neuromuscular disorders, such as CP and Duchenne's MD. In these cases, the underlying disorder was what we treated and there was little focus on the scoliosis itself. I am unaware of what radiographs were taken regarding their scoliosis, but I think CT and MRI in addition to typical radiographs would have been warranted in these cases due to the neurological involvement. With CP especially, I know it's very important to properly position them when treating so they are able to achieve the best upright posture possible. It's also important to recommend proper equipment for home and educate parents so that the scoliosis doesn't become more severe from poor positioning/posture. I have yet to treat idiopathic scoliosis in the clinic and did learn alot from the article in what to expect. You need to look at the patient's spine considering three dimensions instead of only two. I now realize this is a downfall of the Cobb method for measuring scoliosis and the Nash-Moe method is helpful for measuring the rotation component as well.
ReplyDeleteI think this was a good article but I feel like they left out a big demographic that are susceptible to scoliosis even after skeletal maturity, individuals with spinal cord injuries. When I was on rotation at Madonna Rehab on the SCI team scoliosis was a concern when ordering wheelchairs for our patients, especially those with higher level of lesion. Proper cushions, lateral supports and patient education were all very important in the prevention of scoliosis in this patient population. I think it is important to note that scoliosis is preventable in this patient population and the effects of scoliosis could be exponentially debilitating to those with SCI secondary to possible decreased cardiopulmonary status secondary to level of spinal cord injury.
ReplyDeleteI have not seen a patient yet that I have treated for scoliosis. I’ve had patients that I believe had some scoliosis but it was secondary to other problems such as muscle imbalance and I treated the muscle imbalance. So something that I have learned from this article that is going to help me in the future in the diagnosis and treatment of patients with scoliosis is first the part about primary and secondary or major and minor curves. I knew that a lot of times a second curve develops to compensate for the change in balance and so forth. I didn’t realize that the major curve is considered the structural curve and is not correctable with ipsilateral bending, but the compensatory curve can be corrected with ipsilateral bending and that it is necessary to work on this curve so that it doesn’t progress into a structural curve due to ligament shortening resulting from growth retardation on the concave side. I thought secondary curves couldn’t ever turn into a structural curve. So I will now work with patients not only to correct muscle imbalances and teach them compensatory techniques to decrease the progression of a primary curve and educate on brace use, but will also work with patients to prevent or correct the secondary curves if they exist.
ReplyDeleteI did not have the chance to see patients with scoliosis at my clinical rotations. However, I have a good friend who adopted a son with scoliosis that was treated at a young age with surgical and non-surgical intervention. I learned from their experience the vast amount of imaging that had to be done to get accurate measurements for realignment of the scoliosis with growth. These included AP and lateral radiographs with CT and MRI imaging. Their son also has developmental delay which must be taken into account with physical therapy intervention. This article helped demonstrate the importance of a three dimensional view of the spine to correctly access the complexity of scoliosis and also demonstrated the use of Nash-Moe method to address rotation as well as primary and secondary curves.
ReplyDeleteIt is also important to note from this article that you have to take into effect the treatment of the primary and secondary curves to treat the scoliosis thoroughly and look at muscle imbalance and correction. Most importantly to educate the patient and family on the complexity of the musculoskeletal problem and get them vested in the therapy and outcomes.
This was a great article explaining the various types of scoliosis and why and when additional imaging techniques beyond the standard radiograph should be used. This article also did a good job emphasizing how the Cobb angle measures the angle of the curve but does not take into account the rotation that also occurs. I have not treated a patient with scoliosis for back pain. I did see a 61 year old female with a frozen shoulder during my last clinical rotation that had scoliosis. She had idiopathic scoliosis with a right thoracic curve. She had not had any recent imaging or treatment for her scoliosis but said in the past she had only had plain radiographs taken never a CT or MRI. She also said that she wore a brace for a short period of time when she was younger but has never received any other treatment. She is a good example of a patient with idiopathic scoliosis that does not have back pain.
ReplyDeleteThis article was a nice summary of scoliosis. I have seen several patients with scoliosis but all were pediatric patients who were being treated for other conditions and I do not have enough information about them to accurately discuss their scoliosis. I think the information regarding the probability of progression was interesting and potentially useful in my future practice. I was unaware the scoliosis only progresses during periods of growth and is usually complete when the individual stops growing. Those individuals with a Cobb angle of greater than 50 degrees have a high probability of severe progression and cardiopulmonary complications, according to this article. Curves with Cobb angles of 30-50 degrees are projected to progress 10-15 degrees per year and curves of greater than 50 degrees progress 1 degree per year after skeletal maturity. The two greatest factors that influence progression are the severity of the curve at presentation and the spinal growth velocity. The Risser Index is also a useful predictor of skeletal ossification. This articles recommends that patients with scoliosis have a follow-up appointment every 4-12 months regarding their curve progression.
ReplyDeleteIn my clinical rotations I did not treat a patient specifically for scoliosis. While reading the article I realized I was not aware of the 2 classification systems used for anatomic or morphologic descriptions of idiopathic scoliosis curves. The article discussed the Lenke vs the King classification systems. The Lenke classification was described to be a more widely used scale and numerous reasons were given as to why. The article described the many pitfalls of the King system. I thought this was interesting and would be helpful when looking at radiographs of scoliosis patients. The article also gave a chart outlining the Lenke classification system which would be a great thing to reference.
ReplyDeleteThe majority of patients I have seen with scoliosis have been older adults, resulting from a degenerative process. I have seen two teenage girls with idiopathic scoliosis. The most current was at my last clinical. She was a volleyball player who came in with LBP. She had never been told she had any degree of a curve in her spine. The scoliosis wasn't obvious with initial subjective information and observation, but when asked to forward flex, it became apparent. Initially, it seemed to be an instability issue of the low back, and also the shoulder. After discovering the mild scoliosis, there was a more in-depth reason for her pain. Unfortunately, she came in initially during my last week of my clinical. I would have wanted to monitor the curve of her spine to gage the degree of curvature initially, and the rate of progression. A standard AP or PA radiograph would be indicated at this time to determine the Cobb angle, and then repeated in order to, again, determine the stage and rate of progression in order to monitor/modify her POC.
ReplyDeleteMy most recent patient that I treated with scoliosis was a 17 year old female who was coming to therapy for back pain. She had been recently diagnosed with Idiopathic adolescent scoliosis. She had a major right thoracolumbar curve and a compensatory minor left thoracic curve. She was a Risser 5. Her scoliosis was not caught until she was 16 years old and her mother was fitting her for a bra and noticed that her back looked funny. She was an interesting/challenging patient for a number of reasons, the biggest one being that all the doctors told her that scoliosis does not cause back pain, yet she had back pain. She had a number of different x-rays and I cannot remember all of the ones that where in her chart, but she had at least an AP and a lateral radiograph. She also had an MRI due to her complaints of back pain and was found to have a large protrusion at L4/5. After reading the article, I can see why the first doctor did not take an MR image. At first she was only examined for scoliosis, then when she had pain that was only getting worse, that warranted further investigation into the cause of the pain. The access to radiographs and MRI was very convenient and it was great to see exactly what was going on. Her curve was much more dramatic in the radiograph than in person, so it was a good reminder me that things are not always what they appear on the surface.
ReplyDeleteHer treatment consisted of basic stretching exercises to increase spine motion, positioning (prone on elbows) to decrease back pain, core & upper back strengthening exercises, encouraging daily aerobic activity, and IFC as needed for pain control. She responded well to treatment, and with a short set of exercises was able to be successful with daily compliance with HEP and some sort of aerobic activity.
I know I have seen a few kids with scoliosis, but like all the other peds people have said, that’s not really what they’re being seen for primarily, so I couldn’t tell you the details of their scoliosis. In the area I am going to be working in, I will probably be seeing a lot of kids with scoliosis (or the potential to develop scoliosis) that falls in the congenital (fused vertebrae, tethered cord, meningocele, etc.) or neuromuscular (CP, MD, etc.) classifications. According to this article, surgery is the only form of treatment for those with congenital scoliosis. However, those kids that have a neuromuscular scoliosis, may be treated with observation, bracing, and/or surgery. Even though I may not be seeing them specifically for their scoliosis, it is something I will pay more attention to from now on. Bracing would definitely be appropriate for these patients if the curves are significant enough, since kids are skeletally immature. I would say that within the realm of bracing, you could also include positioning, which is something that peds therapists work on a lot, especially for those kids confined to wheelchairs.
ReplyDeleteI have treated several adolescents that were s/p spinal fusion for correction of scoliosis in the acute setting. The patients I saw had a posterior approach, and was very interested in the anterior approach stated in this article. One parent showed me an AP view of the patient s/p surgery to appreciate the extent of the fusion repair. This patient had a spinal fusion from T1-S1 for scoliosis correction, particularly for increased respiration efficiency. This patient was also diagnosed with Duchene’s and has been dependent on all transfers for years. I wonder if the anterior approach would have been beneficial for a fusion of fewer segments to keep from having such a radical surgery.
ReplyDeleteI have seen a few adolescent girls in the clinic for low back pain that have had a palpable scoliotic curve in their spine. No radiographs had been taken and most of them said their Doctor's were monitoring it's progression through yearly physicals. I would imagine Xrays taken from a PA approach would be essential to measure the degree of the curve, as a lateral view would provide a secondary angle to glance at the curvature. One treatment that a CI I observed under did with all of her scoliotic patients was have them laterally shift their ribcage against the scoliotic curve while they inhaled for multiple breaths. I found this an interesting treatment as it would be stretching out tight musculature, fascia, and other soft tissue that may be progressing the curve. One thing I learned in this angle was when bracing is appropriate in the clinic and what types of patients this approach best works for (adolescent idiopathic scoliosis)
ReplyDeleteI worked with a patient who was a 16 year old male who had idiopathic scoliosis. He brought the radiographs with him. He only had an AP view and I think it would have been beneficial to have a lateral view. His scoliosis was in the lower thoracic. It was easy to see that curve, it was starting to make one of his shoulders dip down lower than the other. My CI had not worked with many patients with scoliosis but we started him on stretches and laying over a foam roll and strengthening his trunk and abdominal muscles. To stretch the side which was getting tight on him. The physicians were sure he was going to progress because he had already progressed at the point we saw him. They were just trying to get exercises to slow the progression and he was willing. This article showed me the benefits of different views and how they measure the angles.
ReplyDeleteI have never had a patient who was being seen for scoliosis, however I have had patients with a history of scoliosis or that had minor cases. I never had a chance to see any imaging with these patients because scoliosis was not the chief complaint. I found this to be a very interesting article and what I was most impressed by was the quality of the images that can be obtained. The 3-dimensional view allows you to not only see the curve in the frontal plane but the rotation in the transverse plane as well. For me, the most beneficial part of the article was the treatment section. Even though I know it is usually the Dr.'s call on the treatment of scoliosis, it is good to have some guidelines by which to suggest each type of treatment (observation, bracing, surgery).
ReplyDeleteI've not worked with a scoliotic patient before, but what I found most interesting in the article was how congenital scoliosis is usually linked to some sort of underlying abnormality in the soft tissue or osseous development. I was especially interested in the hemivertebrae--I've never heard of or seen such a thing. It would be interesting to know how some of the coexisting problems affect prognosis for surgical correction. I also wonder how it affects the type of imaging used. The article states that some of those irregularities would not be picked up on an MRI, so I wonder how many times these patients have to have multiple imaging done.
ReplyDeleteI haven't seen a patient with existing scoliosis, but did have a female patient in her 50s who had undergone spinal fusion for scoliosis. I am not sure how her curve was classified prior to undergoing surgery, but I do know that the scoliosis developed in adulthood secondary to pelvic fractures that were never evaluated or treated. I believe the article would classify this as secondary traumatic scoliosis. The surgery involved two intermedullary rods and was done using a posterior approach.
ReplyDeleteThe article was a good reminder on the Cobb technique and principles of treatment--including indications for observation, bracing, or surgery. I didn't realize there was another method of grading scoliosis which included vertebral rotation (the Nash-Moe method), and hadn't heard of the Lenke classification of curve types, so that was informative.
My most recent patient with scoliosis was referred to PT for hip pain and lumbosacral neuritis after delivering her first child. She had idiopathic adolescent scoliosis with a major lumbar curve and a minor thoracic curve, with her lumbar curve measuring around 27 degrees at her last assessment with her physician. She was not receiving any intervention for scoliosis, but was being monitored every 18-24 months. I did not have access to imaging of her scoliosis since that isn't was she was referred for, but an AP view would have been ideal, possibly including standing lateral and SB views.
ReplyDeleteI think the article was good at explaining how to describe different types of curves, as well as how the curves are measured and analyzed. I also like how it described treatment methods based on types and degree of scoliosis.