Author: Elizabeth Wells, MD
Scoliosismaybecongenital,neuromuscular,degenerative,oridiopathic.The spine should be examined in all pediatric patients as part of routine newborn and annual exams. Idiopathic scoliosis is seen in otherwise healthy, rapidly growing preadolescent and adolescent children (typically grades 5–9). Females require treatment five to eight times more frequently than males. It is important to ask about scoliosis when obtaining a family history, as there is a 20 times more frequent occurrence of scoliosis in patients with an immediate family member affected.
During the examination, the child's back should be fully exposed. The pediatrician should instructolder children to stand up straight with feet together, shouldersback,andhandshangingattheirsides,headupandlookingstraight ahead. Signs of scoliosis include asymmetry of shoulder height, scapulae, or flanks (sometimes seen as a bony prominence) or misalignment of spinous processes. After inspecting the back in an upright position, the examiner should ask the child to bend forward at the waist (with feet and palms together) and check again for asymmetry. This forward-bending test to check for thoracic asymmetry is the single most important screening technique.
The American Academy of Pediatrics recommends that infants, children, and adolescents with severe scoliosis be referred to a pediatric orthopedic surgeon. The orthopedist will conduct a standing anteroposterior roentgenogram of the spine to confirm the diagnosis. Treatment recommendations will depend on the degree, flexibility, and location of the curve. Current guidelines are to follow closely every 3 to 6 months with spinal radiographs and photographs for <15-to 20-degree curvature; to use a Milwaukee brace for between 20 and 40 degrees; bracing or surgery between 40 and 50 degrees; and spinal fusion for >50 degrees.
As severe scoliosis (>50–60 degrees) requires treatment with surgical spinal fusion,pediatriciansmustrecognizescoliosisatearlierstagesinordertoavoid major surgery. Nonsurgical treatment is preferred, because back surgery, in addition to the general risks associated with surgery and anesthesia, can be associated with problems, such as nerve and spinal cord damage. Left untreated, the lateral curve will continue to grow until skeletal maturity is reached, usually between ages 13 and 16 for girls and 14 and 17 years for boys. Without surgery, severe scoliosis may irreversibly limit vital capacity and impair cardiopulmonary function, leading to pulmonary hypertension and congestive heart failure.
Although most children with scoliosis are otherwise structurally normal, it is important not to miss a broader developmental problem of which lateral spinal curvaturerepresents onefeature. Infants with scoliosisshouldbeevaluated, usually with radiographs, to determine whether it is due to in utero compression or malformation of vertebral bodies. A patient with malformed vertebralbodiesshouldbecarefullyexaminedforothermalformations.Older children with scoliosis should be evaluated to determine if the scoliosis is acquired or the result of a programming deficit. A child who is short, disproportionate, or has altered structures of long bones should receive a skeletal survey to rule out a skeletal dysplasia or metabolic bone disease. Skin should be thoroughly inspected to rule out a neurocutaneous syndrome, such as neurofibromatosis or incontinentia pigmentosa. If severe mental retardation is present in an adolescent boy with scoliosis, short stature, and coarse facies, Coffin-Lowry syndrome should be considered. Primary neuromuscular disease may be the cause in older children with scoliosis, if the neurologic exam reveals weakness, altered deep tendon reflexes, poor coordination, or gait disturbances. Finally, connective tissue differences should be considered, and ophthalmic and cardiac evaluation should be pursued when other abnormalities in support structures (e.g., marfanoid body habitus, generalized joint laxity, subluxed eye lenses) are recognized.
All children should be examined for scoliosis. Classification of the scoliosis and evaluation for underlying causes will depend on the age at presentation and associated abnormalities. Pediatricians must give particular focus to the spine during the adolescent growth spurt to prevent the consequences of surgery or untreated disease.
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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.
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Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6 
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