Adolescent Idiopathic Scoliosis

detected at the time of adolescent growth spurt
most common is right thoracic or double curve with right thoracic & left lumbar
progression is defined as 5 degree change in the curve
factors related to curve progression include a larger magnitude at presentation & also the skeletal maturity where the immature Risser 0 & 1 are more likely to progress

Approach

rule out intraspinal pathology for left thoracic – incidence will be ~20%
on assessment if curve is <25° reassess in 4 months
if curve is 30-40° & the child has significant growth remaining Risser 0,1 brace the child immediately

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Milwaukee Brace – cervicothoracolumbosacral

TLSO is used if apex is below T8 & currently the Boston brace with a chest pad is advocated

Child wears the brace 22 hours a day

Follow Q 4 months with an xray in brace

Wean at skeletal maturity by decreasing by 4 hours every 4 months

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Indications

Preoperative

Select fusion area
- Curve pattern is identified base on clinical & xray
  - Single major curve
  - Double major curve
- King & Moe
  - True double major – fuse both
  - False double major – implies that the lumbar is flexible & goes away – fuse thoracic
  - Thoracic Curve
  - Long thoracic curve
  - Double thoracic curve – fuse both
- All major curves must be fused
- Fuse to the end vertebrae of the curve with neutral rotation
- Caudal vertebrae must be in the stable zone defined by the line from the spine of S1 which must pass between the pedicles
- Avoid fusing to L5 consider L4 fusion
Approach
- In general, posterior
- Anterior fusion may be indicated in skeletal immature patients, patients with severe – stiff – curves & those whom may get several motion segments saved

Instrumentation

First generation – Harrington Rods – distract the concavity & compress the convexity
Second generation – Luque – segmental fixation with sublaminar wires
Third generation – Cotrel Duboset – multiple hooks & possible pedicle screws

deformity occurs in 3 dimensions & pure distraction leads to hypolordosis & hypokyphosis

3rd generation instrumentation can lead to 3 –D correction via rotation

Safety