Evaluation of the Patient with Scoliosis
Scoliosis may occur throughout growth and devlopment. The most common form, adolsecent idiopathic scoliosis (AIS), usually becomes apparent during the adolescent growth spurt. Infantile and junvenile forms of scoliosis become apparent earlier in development. Initial inspection of the newborn is the first chance to identify an underlying pathology that ultimately may lead to the devlopment of scoliosis. Initially, obvious trunk asymmetry is absent. Close observation of patients with congeital or skeletal abnormalities may lead to early detection of spinal deformity, which will allow for timely and effective treatment. Some anomalies such as congenital kyphosis, whether from failure of formation or segmentation, may be difficult to identify in the very young child. Other congenital pathologies such as hemivertebrae may result in severe scoliosis. These congenital pathologies may not become clinically apparent until the child attains an upright, umbulatory stance. Occasionally early surgical intervention using a short segmental fusion may be effective for some of these congenital deformities. However, leaving the focal deformity untreated may lead to significant proximal and distal structural curves that require extensive, multilevel surgical intervention.
Evaluation of Spinal Deformity
Clear documentation of the patient's medical history, developmental milestones, and growth history are important during the early assessment for spinal deformity. Many somatic and central nervous system syndromes have been associated with scoliosis. A history of cognitive or auditory disorders, as well as visual, cardiac, renal, and dwarfing conditions may be associated with scoliosis.
Occasionally spinal deformities will be identified during the work-up for one of these nonspinal abnormalities. The clinical significance of scoliosis must be considered in relation to the patient's growth history and pubertal status. For girls, the onset of menses is an important indicator of developmental maturation. Typically the growth rate of girls begins to slow with the onset of menses. Growth will continue to some degree for approximately 2 years after menarche. In boys the appearance of axillary and facial hair generally is a sign that is equivalent to the onset of menses. Boy's growth continues into late adolescence, whereas girls' growth tends to slow or stop in the midteens. Peak growth velocity occurs approximately 6 to 12 months prior to the onset of menses in girls and the onset of axillary and facial hair in boys. Closure of the triradite cartilage signals the end of this peak growth spurt. Another convenient radiographic parameter to assess remaining growth is the Risser Sign. The most immature patients will have no iliac apophyseal capping. The iliac apophyseal develops from lateral to medial. The mature patient will have a fully developed and fused apophyseal cap. During the peak growth spurt in particular, and to some degree as long as iliac apophysis remains open, patients are at risk for curve progression.
Tanner Stages in Girls and Boys
| Breast Staging | Genitalia Ratings | |
|---|---|---|
| Preadolescent; elevation of papilla only | Preadolescent; testes, scrotum and penis are about the same size and proportion as in early childhood | |
| Breast bud stage; elevation of breast and papilla as a small mound, enlargement of areola diameter | Scrotum and testes are enlarged with change in texture of the scrotal skin with slight reddening of the skin | |
| Further enlargment of breast and areola, with no separation of their contours | Increase in size of the penis, in length mainly but also in breadth, with continued growth of the testes and scrotum | |
| Projection of areola and papilla to form a secondary mound above the level of the breast | Further enlargment of the testes, scrotum and penis with development of the glans and darkening of scrotal skin | |
| Mature stage; projection of papilla only due to recession of the areola to the general contour of the breast | Genitalia adult in size and shape |
| Pubic Hair Stages | Pubic Hair Stages | |
|---|---|---|
| Preadolescent; no pubic hair | Preadolescent; no pubic hair | |
| Slight growth of long, slightly pigmented downy hair, appearing chiefly along the labia | Slight growth of long, slightly pigmented downy hair, appearing chiefly at the base of the penis | |
| Darker, coarser hair that is more curled and spread sparsely over the junction of the pubes | Darker, coarser hair that is more curled and spread sparsely over the junction of the pubes | |
| Hair is adult in type with no spread to medial surface of the thigh | Hair is adult in type with no spread to medial surface of the thigh | |
| Adult in quantity and quality with no inverse triangle distribution and spread to the medial thighs | Adult in quantity and quality with no inverse triangle distribution and spread to the medial thighs |
Evaluation of Spinal Deformity
Clear documentation of the patient's medical history, developmental milestones, and growth history are important during the early assessment for spinal deformity. Many somatic and central nervous system syndromes have been associated with scoliosis. A history of cognitive or auditory disorders, as well as visual, cardiac, renal, and dwarfing conditions may be associated with scoliosis.
Occasionally spinal deformities will be identified during the work-up for one of these nonspinal abnormalities. The clinical significance of scoliosis must be considered in relation to the patient's growth history and pubertal status. For girls, the onset of menses is an important indicator of developmental maturation. Typically the growth rate of girls begins to slow with the onset of menses. Growth will continue to some degree for approximately 2 years after menarche. In boys the appearance of axillary and facial hair generally is a sign that is equivalent to the onset of menses. Boy's growth continues into late adolescence, whereas girls' growth tends to slow or stop in the midteens. Peak growth velocity occurs approximately 6 to 12 months prior to the onset of menses in girls and the onset of axillary and facial hair in boys. Closure of the triradite cartilage signals the end of this peak growth spurt. Another convenient radiographic parameter to assess remaining growth is the Risser Sign. The most immature patients will have no iliac apophyseal capping. The iliac apophyseal develops from lateral to medial. The mature patient will have a fully developed and fused apophyseal cap. During the peak growth spurt in particular, and to some degree as long as iliac apophysis remains open, patients are at risk for curve progression.
