The radiographs are standardized.
They are postural - meaning they are weight
bearing and they are posterior to anterior.
The indication is when you have a 7
degree finding on the scoliometer.
you need to move to an x-ray as well and
look for an obvious spinal curve on x-ray.
The thoracic or lumbar assymetry that you
see on physical exam is gonna be different
when done with an x-ray.
And this is an important standardization, an
important marker of what's going on with the spine.
So initial radiograph of scoliosis
should be done standing,
i.e. weight bearing, full-length
that should get the whole spine
and give you the relationship
of the spine to other areas,
and you want tp get a PA and a lateral.
The PA view minimizes the radiation needed,
and it doesn't get the soft tissue
of the organ systems so it's safer
because you're gonna be doing
it on a regular basis.
and that's the opposite view of a typical
chest x-ray which is typically an A-P
so it's looking from behind.
When you get the initial radiograph, it
should get the whole spine and the body.
It is looked at as a single x-ray so you get
a good sense of what the person looks like
and again, you do not want to do an anatomic
x-ray, you don't take the weight off the person,
you want it standing, postural so you
get a good sense of what's going on.
The scoliosis will change whether it's
weight-bearing or non-weight bearing.
So again, the standardixation for an x-ray
in evaluating for scoliosis is postural.
It's standing, and it's
posterior to anterior.
For true leg-length discrepancy,
not a short leg syndrome,
you wanna make sure that that's fixed and
treated to help minimize what's going on.
And if you want to determine the scoliotic curve,
you want to fix the leg-length discrepancy
before you go ahead and do the x-ray.
You also can get lateral bending films which
will tell you what the functional ability is
and over time that will be a good sense of what
actions and activities or motions are lost,
and it will give you a better sense of when
you might need a surgical intervention.
Here's a description of the Cobb
method of radiographic evaluation.
How do you measure the spine with the x-ray?
Where do you put the lines and
where do you get the angle?
So thpis is gonna show you where you're gonna put the
line on the superior border of the highest vertebrae
which is where the scoliosis begins.
And you extend that line towards
the concavity of the curvature
and where those two lines meet
will give you the Cobb angle.
And the description is right here, and that's how
you're gonna go ahead and get the assessment.
If you wanna check for curve
progresson, you wanna get regular P-As
and regular measurements of the
angle to see how it's changing.
You also wanna know the convexity and name the
scoliosis based on the side that has the convexity.
You want to identify the apical
vertebrae where the curvature starts,
and we classify this into cervical
C2 to C6, Cervicothoracic C7 to T1,
Thoracic T2 to T11, Thoracolumbar T12-L1,
Lumbar L2-L4, or Lumbosacral L5 or below.
A typical curve in adolescent scoliosis is a double
courve, that's typically right thoracic and left lumbar.
The other thing the x-ray will do, at least
the first x-ray will give you a sense is
to whether or not there anre congenital anomalies
or changes in the musculoskeletal system
that need to be followed
or evaluated differently.
You get a sense of the paraspinal
masses, and how they're affecting it.
It will tell you whether there is the
presence or absence of hemivertebrae
or a wedged vertebrae or a
partial vertebrae there.
And it will tell you if the vertebral body has any
erosions or risk of cancer or other abnormalities.
Those are things that you
should take into consideration.
Oftentimes, the radiologists would
check the interpedicular space
to assess for widening or shortening.
This will tell you if there's a risk for
spinal cord tumor or spinal cord injury,
syringomyelia, or cavitation that
exists within a spinal segment.
So these are just general things you
want to take into consideration.
When you have a patient with scoliosis, one
thing we do is determine the bone age.
You want to know when they're gonna be growing
and how long they're gonna be growing.
There are a number of different
ways to check bone age.
One is an x-ray of the apophysis looking
at the hips, looking for Risser sign.
You can check an x-ray of the apophysis of the distal
radius, the ulnar and the small bones of the hand,
that's called the Tanner
and Whitehouse method.
You can check an x-ray of an elbow and
that's called the Sauvegrain method.
And you could do a simple olecranon
x-ray to get a better sense.
We're gonna go through the four
different types of bony aging.
For the Risser sign, you want to get
an x-ray of the iliac apophysis
and you wanna see how much ossification
you have of the iliac apophysis.
A Risser sign is a visual grading of that.
If there's no ossification,
that's a zero (0)
and a zero means they have a
long way to go in growing.
If 25% of it is ossified,
you get a 1.
25-50%, a 2.
3 would be 51-75%.
Greater than 76% is a 4.
and full bony fusion
of the apophysis is a 5.
So that's one way.
The next way to measure for bone age
is get an x-ray of the distal wrist
looking at the radius, the ulna
and the small bones of the hand.
And this is called the
And what you're looking for is whether
or not the bony areas have filled up
what their relationship is and how
much further growth they have.
So we have good ways of seeing
growth from the wrist x-ray.
The third method is an x-ray of the
elbow called the Sauvegrain method.
And you'll look at the four ossification centers
- the lateral condyle, trochlea, the olecranon
and the proximal radial epiphysis.
And you score it in a 27 point scale
and then plot it in the graph.
And the last x-ray, the fourth
x-ray is the x-ray of the elbow
just assessing the ossification
centers of the elbow.
It's called the simple olecranon method and it basically
looks to see if you have a single ossification,
a half-moon ossification, or there is a rectangular
shape ossification center on the elbow.
Once you see the things have fused, you
know that the growing has completed.
With complete fusion, you can say that
bone age has reached skeletal maturity.
Occasionally, x-rays are not enough.
If you have an early onset of scoliosis,
the need to move to an MRI is heightened.
If the patient has other symptoms that
make you worry about cancer or malignancy,
you need to move to an MRI.
If you're worried about traumatic
fracture or other bony abnormalities
possibly an osteogenesis imperfecta or
frequent breaks, you may want to go to an MRI.
And if you're worried about a tumor or an infection, a
CT or an MRI is also indicated for further information
in order to get the best
if this patient has any neurologic symptoms
like headache, neck pain, weakness, foot drop;
If they have a loss of abdominal reflex
or assymetric lower extremity reflexes
if you notice atrophy in one area or
another, or pes cavus in the chest,
those are signs that you need to look further and you
may want to get an MRI to evaluate the scoliosis.
If you have any abnormal
findings on plain radiographs,
then you want to go further and you wanna
confirm those findings on the CAT scan or MRI
more likely an MRI because it gets soft
tissue and will give you further information
that you're not geting on x-ray.
When do you need to refer
a patient with scoliosis?
Well the answer is anybody with a severe curve
should be seen by an orthopedic specialist.
If the angle is severe, and you
can't get a good measurement
then you may want help getting the
measurement because that's critical
for knowing what you're gonna
Patients who have a Cobb angle between 20 and 29
degrees may eventually need surgical intervention
and getting them to the orthopedist
early is gonna be helpful.
If they have a Cobb angle greater than 30 degrees, and
you know you're gonna have some organ involvement
getting the orthopedic specialist
involved is gonna be good.
And any rapid progression of the Cobb angle
more than 5 degrees in a single visit space
indicate something may be changing quickly and
that patient should be referred to an orthopedist.
At the same time of referral, it is
important to maintain your measurements,
continue what you're doing and
stay involved in the care because
you're gonna be monitoring and taking
care of this patient, long-term.
You don't want to send them to an
orthopedist for incidental finding.
It's mostly gonna be for definitive treatment
or just help in measuring and figuring out
how to name and how to witness
the disease going forward.