Presentation of Scoliosis

by Tyler Cymet, DO, FACOFP

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    00:01 In terms of presentation, we say that in children, adolescents and adults, they're often asymptomatic.

    00:07 And that's because the symptoms are mild, they're hard to associate with a chronic condition when the symptoms are transient.

    00:15 In children, we check them for scoliosis before their growth phase, usually 10 to 12 in girls, 13 for boys.

    00:22 In adolescents who are also asymptomatic, they will notice complaints with clothes not fitting and noticing the asymmetry.

    00:29 That's a common thing that drives them to the hospital or to a doctor.

    00:32 It's the question of, "Is this normal that there is an asymmetry in the body?" With adults, we'll often hear complaints of osteoarthritis and back pain and just general aches and pains in the back and neck region.

    00:46 You will hear complaints of chest pain as the next most common.

    00:51 And you could potentially have dysfunction of the heart and lungs.

    00:55 The scoliosis presentation we generally found on a screening exam, once it presents to the doctor, once you see it, you're gonna have to take it more seriously and get a more objective assessment.

    01:09 You're gonna need to solidify the diagnosis with an x-ray and a spinal examination preferrably before the growth spurts you can monitor overtime.

    01:18 But these are important points in evaluating a child with a scoliosis.

    01:23 The evaluation is to make sure there is not a cancer, not trauma, no fracture and assess for more serious etiologies.

    01:33 You wanna measure the magnitude of the curve with a PA x-ray and you may wanna use a Cobb, tool to measure as well which is not the same but it will give you a sense of what the curvature is.

    01:47 You also wanna note the age of onset, any progression the family has noted or changes the family has shared with you overtime, any pain or discomfort.

    01:57 What can't the patient do or what they could do before, what limitations do they have? Are there issues with throwing, standing, walking, getting upstairs, getting downstairs, those are all questions you want to address to the parents.

    02:10 You also want to know when to expect the growth spurt.

    02:13 Has there been menarche in girls? Has there been infection, arthritis, trauma? Has the patient been hospitalized? Have they had bony infections? These are all good things to know.

    02:26 In the physical evaluation, make sure you know any abnormal, physical findings, any asymmetries and any areas that look like there might be where the change is occuring.

    02:38 During your exam make sure you note the height because again, with scoliosis, you will have a change in height and you wanna note when that happens.

    02:47 You wanna note the stage of puberty so you'll understand when the growth phase is gonna occur and when you need to be focusing on changes in the curvature of the spine.

    02:56 A solid neurological exam is necessary because a lot of the conditions causing scoliosis also have neurologic effects as well like neurofibromatosis.

    03:06 So you wanna check the patient's ability to walk, toe walk and heel walking is good.

    03:11 Deep squatting or what we call duck walking.

    03:13 Are they able to hop on each leg and can they do a 30 second stand on each leg? What kind of balance issues do they have and has that been affected? You also wanna include notation of any reflexes particularly the abdominal reflex.

    03:26 You wanna examine the skin looking for cafe-au-lait spots, again, neurofibromatosis or any vascular or hyperpigmented lesions or patches that are overlying the spine If you notice skin or joint laxity that can lead you to worry about Ehler-Danlos syndrome or other issues of joint laxity that can lead to a scoliosis.

    03:46 Are there any notes or signs of flat feet, high arches or changes in the feet? Any hammer toe or claw toe deformity? those issues can give you a sense of what the ideology is and what you have to worry about later on in life.

    04:01 You also want to observe for symmetries looking at the arms and the shoulders and the neck and the occipital region.

    04:07 You wanna check the level of the occiputs, the shoulders, the iliac crest, the PSIS, the PIIS and the greater tronchanters.

    04:14 And you wanna measure the leg lengths to make sure there is no inequality of leg length, not the short leg syndrome we talked about in the other video, but a true change in the length of leg which usually happens from a fracture or other trauma related issues.

    04:30 When you do the test, the Adams forward bending, you basically just wanna stand in front of the patient and have them bend forward and see if the curvature seems to go away and what kind of functional deficit you may have.

    04:41 You also wanna run the fingers along the paraspinal musculature and along the spinous processes.

    04:48 We say if there's tenderness or pain on the spinous processes, you wanna look for malignancy or other abnormalities like trauma or fracture that would be more likely and needs to be evaluated for.

    04:59 If there's any problems with walking or problems with balance, those are important things that need to be evaluated further as well.

    05:07 A scoliometer is a carpenter's tool that will measure the angle.

    05:10 It's definitely PA x-ray, it will give you a different score and it should be noted differently than what you're noting on the x-ray.

    05:18 You want to use the same tool each time when you measure the curvature of the spine.

    05:23 So with the scoliometer, it will give you a sense of the curvature but again, if you're gonna use that everytime, use the same one and have consistency.

    05:32 So it's important to remember when you evaluate a person with scoliosis that the scoliometer is not the equivalent to the Cobb angle and their different measurements.

    05:40 A general guideline is that the angle of trunk rotation is of 7 degrees is gonna have a Cobb angle of 20 degrees.

    05:48 So the Cobb angle is gonna be greater.

    05:51 The operator-dependent measurements needs to take into account things that cause error.

    05:56 So if you don't forward bend them all the way on the same degree or the same way, you're gonna get inconsistent measurements.

    06:03 If you're not measuring from the top vertebrae, you're gonna get an inconsistent measurement.

    06:09 So make sure you have a consistent, standardized way of measuring the angle so you get a good sense of what's going on.

    06:16 When you measure scoliosis, we're generally pretty good at it.

    06:19 The inter-rater reliability is that generally with the thoracic curves, two different people measuring the curve are gonna vary by about 2 degrees.

    06:28 On the lumbar spine it's about 2.2 degrees and when you have the intra-rater variability, how much one person is gonna vary in redoing their measurement? it's about 1.2 degrees in the thorax and 1.6 degree in the lumbar spine.

    06:45 So we're pretty good at measuring it.

    About the Lecture

    The lecture Presentation of Scoliosis by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Scoliosis – Presentation
    • Scoliosis – Evaluation

    Included Quiz Questions

    1. The angle of trunk rotation (or trunk asymmetry)
    2. The Cobb angle
    3. The length of the spine
    4. The width of the spine

    Author of lecture Presentation of Scoliosis

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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