Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

Chapter 48: PEDIATRIC SPINE

1. How is screening for idiopathic scoliosis performed?

The Adams forward bend test is a basic test used to detect trunk rotation
An inclinometer is measures trunk rotation and is accurate; 7 degrees or greater is the
guideline for referral

2. What is the most reliable method to predict both cessation of growth and curve
progression in scoliosis?
Peak height velocity

3. What magnitude of curve in idiopathic scoliosis is likely to progress after skeletal

maturity?
Less than 30 degrees: unlikely to progress
More than 50 degrees: progresses in the majority of cases (at 1 degree per year on average)

4. What is the interobserver variability with the Cobb technique?

5 to 10 degrees

5. What are the indications for preoperative MRI in idiopathic scoliosis?

Spinal pain out of proportion to the deformity; atypical radiographic curve patterns such as
left thoracic curves; radiographically documented rapid curve progression; abnormal findings
on physical examination (such as neurologic abnormalities)

1
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

6.

When is bracing indicated in the treatment of idiopathic scoliosis?

For curves between 20 - 40 degrees in patients with significant growth remaining (Risser 0-3)
For a curve with the apex at T8 or below, a Boston brace (TLSO) is used
For a curve with the apex above T8, a Milwaukee brace (CTLSO) is used

7. When is surgical treatment indicated for idiopathic scoliosis?

In skeletally immature patients with curves greater than 40 to 50 degrees
In skeletally mature patients with curves greater than 50 degrees (especially those with
significant frontal or coronal trunk imbalance)

8.

What is the standard surgical treatment for idiopathic scoliosis?

Posterior spinal fusion and instrumentation

9. What are the advantages of anterior spinal fusion (versus posterior) and when is it
indicated?
Anterior instrumentation systems provide higher coronal plane correction and have a better
ability to restore a normal thoracic kyphosis
Fusion levels can be saved when using an anterior approach, at the expense of a higher rate
of pseudoarthrosis, rod breakage, and loss of correction
Anterior diskectomy and fusion is used for severe and rigid curves or for patients with open
triradiate cartilage in order to avoid a crankshaft phenomenon

2
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

10. Why should magnetic resonance imaging of the brain and spinal cord be obtained
in patients with infantile and juvenile scoliosis?
Because of the high incidence of underlying neural axis abnormalities

11. When is treatment indicated in juvenile scoliosis?

For progressive curves 25 degrees or greater
Nonoperative treatment consists of casting followed by bracing
Surgery is indicated for progressive curves greater than 60 degrees that have failed
nonoperative modalities

12. When is surgery indicated in the following types of neuromuscular scoliosis?

Cerebral Palsy
Curves greater than 50 degrees with progression greater than 10 degrees in patients 10 years
of age and older
Duchenne Muscular Dystrophy
Progressive curves greater than 30 degrees and a reduced forced vital capacity
Myelomeningocele
Progressive curves more than 50 degrees
Lack of posterior elements leads to an increase in pseudoarthrosis if posterior instrumentation
and fusion are used alone; thus combined anterior/posterior fusion may be preferred

13. What is the most rapidly progressive and severely deforming of all types of
congenital scoliosis?
Unilateral unsegmented bar with a contralateral hemivertebrae
3
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

14. What is the treatment of congenital scoliosis?

Bracing is not indicated because congenital curves tend to be rigid and refractory to bracing;
surgery (arthrodesisPSF, ASF or combined) is the only effective treatment

15 Discuss the different types of congenital kyphosis

Type I: failure of formation
Type II: failure of segmentation
The apex of the kyphosis is typically between T10-L1

16. What is the treatment of congenital kyphosis?

Treatment is surgical
Progressive kyphosis less than 60 degrees: posterior fusion with autologous bone graft;
this should include one level above and below
the defect
Kyphosis greater than 60 degrees:

anterior release and fusion followed by posterior

spinal compression instrumentation and fusion

4
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

17.

What is Scheuermanns disease and how is it treated?

Rigid kyphosis with anterior wedging of 5 degrees or more of at least 3 adjacent vertebral
bodies (classic type I disease)
Bracing is indicated in
skeletally immature patients with a curve of more than 50 degrees with
significant pain
a cosmetically unacceptable deformity, or
documented progression
Milwaukee Brace: curves with an apex above T7 are best managed with a Milwaukee
brace
Hyperextension TLSO: low thoracic or thoracolumbar kyphosis may be treated with
a hyperextension TLSO
Surgical correction is indicated
for rigid kyphosis of more than 75 degrees in patients who have failed
nonoperative treatment and
have persistent pain or an unacceptable cosmetic deformity
Anterior release and fusion followed by posterior instrumentation and fusion is
generally recommended
Correction should be limited to 50 percent of the initial deformity

18.

What is pseudo-Scheuermans disease?

A condition seen in the lumbar spine in active adolescent males involved in sports or
physical activities; etiology is speculated to be associated with axial loading of the immature
spine
These curves are nonprogressive and treatment is based on rest and activity modification

5
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

19.

What is the most common side effect of abdominal (and spine) irradiation?

Spinal deformity (incidence is up to 50 percent after Wilms tumor)

20.

How is scoliosis associated with neurofibromatosis managed?

Idiopathic-like curve patterns are managed similar to idiopathic scoliosis

Dystrophic curve patterns are usually not amenable to bracing; early circumferential surgery
is most effective (anterior and posterior in severe curves)
Dystrophic curves are associated with penciling of 3 or more ribs and development prior to 7
years of age

21.

What are the most common pediatric spinal tumors?

Eosinophilic granuloma: treatment is symptomatic by casting or bracing

Aneurysmal bone cyst: treatment is selective arterial embolization and intralesional
curettage
Osteoid osteoma: treatment is excision of nidus
Osteoblastoma: treatment is open surgical excision
Painful scoliosis is a common presentation of spinal osteoid osteoma and osteoblastoma, and
is considered to be secondary to pain-provoked muscle spasm on the side of the lesion

6
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

Chapter 51: THORACIC DISK HERNIATION

1. What is the most common type of thoracic disk herniation?

Mediolateral

2. What is the most common mechanism for thoracic disk herniation?

A combination of torsion and bending load (the latter may be flexion, extension, or lateral)

3. Thoracic disk herniation typically produces impingement of which nerve root?

The nerve corresponding to the more caudal vertebrae (for example, anterolateral T8-9 disk
herniation will produce a T9 radiculopathy)

4. What is the natural history and treatment of thoracic disk herniations?

Most patients do well with nonsurgical measures; less than 2 percent of thoracic disk
herniations are treated surgically each year

Surgical indications include myelopathy, progressive neurologic deficit, continued pain

despite minimum 6 months of conservative management

Multiple surgical approaches have been described

Fusion should accompany diskectomy in cases which involve multiple levels

Instrumentation is not routinely used for fusions due to the inherent stability of the
thoracic spine, except in cases of multilevel diskectomy at the thoracolumbar junction

7
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..

Orthopaedic Knowledge Online: Orthopaedic Review

http://www.aaos.org/oko
Author: Ryan Dopirak, MD
Editors: John Sarwark, MD and Michael DeFranco, MD

June 2004
Section 5

5. Why is a chest X-ray an important part of the preoperative work-up in patients with
thoracic disk herniation?
A common error in the surgical treatment of thoracic disc herniation is misidentifying the
level of pathology. The thoracic anatomy can be more variable than in the lumbar or cervical
spine, with a different number of vertebrae and ribs. A chest X-ray is used to count the
number of ribs in order to verify the proper level.

8
1995-2003 by the American Academy of Orthopaedic Surgeons. " All Rights Reserved." This publication and its contents may not be
reproduced in whole or in part without written permission. Please read the Disclaimer agreement carefully before using the
Orthopaedic Review website. By accessing or using the website, you agree that you are competent and of age to enter into this
Agreement and to be bound by the terms and conditions listed therein. If you do not wish to be bound by these terms and
conditions, you should not access or use this material..