Childhood Scoliosis: Diagnostic Steps

Diagnosis
Early diagnosis and treatment helps to prevent curve progression and deformity. Scoliosis left untreated may progress leaving the spine abnormally curved, stiff, and sometimes rigid. This makes treatment difficult and increases the risks for serious complications.

Medical and Family History
The patient, parents, and physician discuss the medical and family history. The physician looks for any underlying medical condition that might be causing scoliosis. A family history of the disease or other attributing medical disorders is noted. The patient's age, onset of puberty, or menarche (girls) helps to determine the number of years remaining until the child reaches adulthood, at which time curve progression may cease.

Physical Examination
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam provides a baseline from which the physician can measure the patient's progress during treatment. The physician will observe the patient standing (front and back) and look for any asymmetric abnormalities in the shoulders, rib cage, waist, and pelvis.

Patients with scoliosis may present humpback, one hip higher than the other, or listing to one side. In severe scoliosis, cardiopulmonary (heart/lung) function is tested. The physical examination also includes:

1. Adam's Forward Bending Test requires the patient to bend forward at the waist. Viewed posteriorly (from behind), scoliosis is suspected if a thoracic (mid-back) or lumbar (low-back) prominence is apparent.

2. A rib hump can be measured in degrees using a Scoliometer. While the patient is bent at the waist, the scoliometer is placed over the rib hump.

3. Leg length is measured and compared to determine discrepancy.

4. A plumb line held posteriorly at the 7th cervical vertebra (C7) is allowed to hang below the buttocks. In a normal spine, the line passes through the gluteal crease (middle of buttocks). In scoliosis, the scoliotic portions of the spine may fall to the right or left of the line.

5. Palpation determines spinal abnormalities by feel. The ribs (thoracic) or lumbar muscles may feel more prominent on one side of the spine than the other.

6. Range of Motion measures the degree to which a patient can perform movements of flexion, extension, lateral bending, and spinal rotation. Asymmetry is also noted.

Neurological Examination
Patients are assessed for underlying neurological problems that may be causing scoliosis. The following symptoms are assessed: pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes.

Radiographs
X-rays indicate if the scoliotic curves are structural (major) or non-structural (minor). The patient stands to reveal the entire length of the spine when PA (posterior/anterior, or back and front) and Lateral (side) x-rays are taken. Side bending AP x-rays are sometimes used to evaluate spinal flexibility.

Congenital Thoracic Curve

Progressive Curve

Spinal (Skeletal) Maturity
Spinal bone maturity helps to determine curve progression. The Risser Sign radiographically observes the iliac crest growth plate, a fan-shaped part of the pelvis. At maturity, the crest has fused with the pelvis. A hand x-ray can also give information as to skeletal maturation.

Curve Classification
Curves are classified according to pattern (shape) and magnitude (severity).

1. King Classification divides scoliotic curves into one of five patterns. For example, King Type III curves are primarily single thoracic curves, the most common occurring in adolescent idiopathic scoliosis.

2. Cobb Angle Measurement uses a standard full-length AP x-ray. Geometric calculations determine the angle of the curve in degrees.

3. Nash-Moe technique measures pedicle rotation by dividing the vertebral body into segments. The segment into which the pedicle is located quantifies rotation.