Spinal Deformities / 91

3 Excessively anxious patients. In such people, an .x-ray examination is an essential part of treatment; they cannot be reassured by clinical examination alone. J P'.ltientsin whom the history and examination are .:.;gcstiveof an early ankylosing spondylitis. A
specific request should be made for oblique views of the sacroiliac joint.

5. Patientswith clinically apparent spinal deformity. 6. Patients with significant root tension and patients presenting with evidence of impairment of root conduction. It must be remembered that being very athletically inclined does not prevent these young people from having a tumor of the cauda :.::Iina. 7. Ii'severe pain persists for longer than 2 weeks despite treatment, an x-ray examination is indicated, not only to exclude the possibility of some obscure spinal abnormality, but also to reassure patients that they are not suffering from a serious

progressive disease.
On occasion the radiograph reveals a spinal 3n(\m~Jv. the spinal anomalies once believed to cause Of :~",-;"; ,iin, such as sacralization of LS, spina bifida occulta, the ossicle of Oppenheimer, and a unilateral iliotransverse joint, all are now recognized as being incidental findings that have no influence on the developmentof low back pain. There remains just one bone anomaly that givesrise to concern. If the radiograph reveals a spondylolysis of L5 with or without a listhesis, the question alwaysarises whetherthis defect in the pars interarticularis developed ,\, :~'c.'ult of repeated trauma on the football field or ~hcther the patient had this defect before he started playing football. It has been reported, and convincingly demon-

strated radiographically, that linebackers may develop in the course of the season, as a result of the vigorous hyperextensionstrains they place on eachother, a stress fracture through the pars interarticularis, giving rise to a spondylolysis. Without specific therapy and certainly without surgery, over the course of the next 6 months, these stressfractures heal by themselvesand will not be the source of further disability. In patients in whom a routine x-ray examination reveals a spondylolisthesis of grade I or more, the question is always raised whether it is safe to let the young athlete continue with contact sports. There is no evidence that vigorous physical contact will cause an increasingslip. These patients may have a pain derived either from the subjacentdisc, from the syndesmosisat the site of the isthmic defect, or most probably from degenerative disc changes occurring at the level above the slip. Anyone or all three of these factors may be responsible for repeated episodes of discomfort during play and may markedly interfere with the patient's In these patients, there are two choices. Either they must give up contact sports or, if this is going to be their profession,the question is raised whether they should be admitted to the hospital for more detailed analysisof the source of the discomfort, to see whether it is possible to stop abnormal movement at the level of the defect and stabilize the degenerative disc above the slip by a localized intertransverse fusion. It must always be remembered that it will take at least 9 months to 1 year before this young person returns to competitive sports. In the diagnosis and management of a patient presentingwith low back pain, orthopedic surgeonsmust play many roles: family practitioner, internist, radiologist, physiatrist, orthotist, psychiatrist, socialworker, and friend. They should rarely find it necessaryto play the role of their chosenavocation-orthopedic surgeon.

competence.

SPINAL DEFORMITIES
l YlE j. MICHELI, M.D. Ell Y TREPMAN,M.D.

the potential for spinal injury or compromise spinal function during athletic activities. The four major issuespertaining to spinal deformi-

ties are:
1. Detection of spinal abnormalities that may render sports participation ineffective or even dangerous for a child. 2. Early detection of spinal deformity in the child athlete, with the initiation of ongoing assessment or bracing. 3. Effective management of relatively mild spinal deformities with bracing or electrical stimulation techniques and directed exerciseswhile a child continues to participate in sports.

ihe physician dealing with sports-related injuries must have a working knowledge of both normal spinal Contour and structural spinal deformities. The importance of the spine in normal function cannot be overemphasized.It is the structural centrum from which extremity motion initiates, and it contains important elementsof the central nervous systemand the origin of the peripheral nerves. Spinal deformities may increase

92 / Current Therapy in Sports Medicinf'

4. Determinationof the level of athletic participation that is safeand effectivefor a child who has required a spinalfusion.
THE NORMAL AND ABNORMAL SPINE The spine consists of a series of sevencervical, 12 thoracic, and five lumbar vertebrae perched upon the sacrum,and is designed for both stability and movement. In the sagittal plane, this semirigid column has a normal thoracic kyphosis (convex posterior angulation) and lumbar lordosis (convex anterior angulation). The cervical spine is !:apable of a wide range of motion, but normally is postured in a position of slight lordosis (Fig. 1). The degree of angulation of the spine is determined by the Cobb technique (Fig. 2). The angle subtendedby the top of the most tilted vertebra above,and the bottom of the most tilted vertebra below, is defined as the angle of curvature. The range of normal magnitude of theseangulations is controversial. In general, when a person is standing, the normal range of thoracic kyphosisis 20 to 50 degrees; deviations outside these limits are either hypokyphosis ( < 20 degrees) or hyperkyphosis (> 50 degrees). Similarly, the range of normal lumbar lordosis is 20 to 50 degrees (see Fig. 1). The incidence of dorsal (thoracic) hyperkyphosis may be increased among athletically active adolescents, especially males. This condition, known as Scheuermann's kyphosis, is defined as a dorsal kyphosis of more than 50 degrees in which there is at least 15% wedging of at least three vertebral bodies, narrowing of the disc

spaces, and irregularity of the vertebral body end plates. The condition may have a genetic predisposition, or it may be acquired, secondary to repetitive microtrauma on the anterior aspects of the vertebral bodies of the dorsal spine, with resultant wedging. A tight lumbar lordosis may contribute to the problem by preventing adequate forward flexion of the lumbar spine; as a result, with forward flexion, more flexion must occur in the thoracic spine, leading to injury of the anterior aspect of the vertebral bodies, with secondary structural changes and dorsal roundback deformity. Any curvature of the spine in the coronal plane is defined as scoliosis. This condition is abnormal and is therefore considered a deformity, even though 10% of the population may have a mild scoliosis (up to 10 degrees) in some portion of the spine. Scoliosis may be functional- the result of muscle spasm, postural angulation of the spine, or extraspinal factors such as limb length discrepancy or pelvic obliquity. In functional scoliosis, there is no fixed deformity of the spine, and when the causative factor is corrected the spine becomes straight. In contrast, structural scolio~is is a fixed deformity of the spine, although it may be partially corrected with mechanical techniques such as pulsion pressure or traction. The causes of structural scoliosis include (1) paralytic disorders such as poliomyelitis or myelodysplasia, (2) congenital abnormalities of the spine, or (3) idiopathic scoliosis. Rotational deformity of the spine in the horizontal plane is associated with coronal plane deformity in structural scoliosis. Idiopathic scoliosis, the most common type of scoliosis in North America, is often familial, with a

'(I

/ (;-f
Figure 1 The nonnal range of thoracic kyphosis and lumbar lordosis is 20 to 50 degrees.

,/"-<-- r

Figure 2 The Cobb angle, a quantitative measure of spinal curve, is the angle between the top of the most tilted vertebral body at the superior limit of the curve and the bottom of the most inferior vertebral body.

Spinal Deformities

/ 93

.It maybecome at a specific time in the growth and development of the child. The classification of idiopathic scoliosis includes (1) infantile-onset scoliosis, which is during the first year of life; (2) juvenile-onset scoliosis,which begins during the prepubescentperiod; and (3) adolescent-onsetscoliosis, which can develop rapidly and progressivelyonce adolescencebegins. Most conditions that cause scoliosis occur during adolescence.Therefore, it. is ~mportant to

because the deformity may (1)

effectively,and (2) the sports environment, particularly that of organized team sports, provides an excellent opportunity for early detection of a developing spinal deformity. The preparticipation physical examination, which should be performed annually for any child involved in organized sports, should include an assessment and careful measurement of the posture and contour of the body, with special attention to the spine, torso, and pelvis. The child who exhibits symmetric posture on examination may the following year show signs of progressive scoliosis or early kyphosis (dorsal roundback). Abnormalities of posture and contour are carefully assessed school screening programs, which are curin rently mandated in more than half of the United States as well as in Canada. These programs are at least 85% effective in the early detection of spinal abnormalities. In combination with an effective bracing or electrical stimulation program, they can often prevent the progressionof spinal deformity and the need for surgery. DIFFERENTIAL DIAGNOSIS Spinal deformities or structural abnormalities, con.may significantly increasethe risk of sports participation. congenital conditions, such as Down or syndrome, are associated with an increased This of particular concern for Special Olympics competiIn these children, lateral radiographs in flexion and , are recommended to rule out measurable

In the lumbar spine, spondylolysis or spondylolisthesis may result in postural deformity or scoliosis. An athlete with either of these conditions may have increasedtightness of the hamstrings,relative flattening of the lumbar spine with posture, and pain on hyperextension of the spine. Radiographs of the lumbar spine, including oblique views, are usually diagnostic (Fig. 3). If a frank lack of continuity of the neural arch is detected at the pars interarticularis, a standing lateral radiograph of the lumbar spine is recommended to determine the amount of instability at this site, if any,and the coexistence of spondylolisthesis. In our experience, symptomaticspondylolysisor grade I spondylolisthesisin young athletes appears to be a stress fracture of the lumbar spine, and rarely progressesto frank instability. Spinal deformity may be the presenting signof more significant disease, such as localized spinal infection, discitis, or spinal tumor. These conditions may be more common in the young athlete than in the adult, and may present initially with scoliosis. Any spinal deformity or scoliosis that persists beyond 3 weeks and is associated with muscle spasm and pain must be investigated

mm of CIon C2 is a signof ligamentous or laxity. In casesof detected instability, indicationsfor prophylactic

head-impact activities, such as heading the ball in are absolutely contraindicated. . Klippel-Feil syndrome, characterized by shortness of the ueck or webbing, may be associated with cervical spine. In th~se extension views of the ce1"':ical spine may also .be allowing such activity.
Figure 3 Spondylolysis, defect in the pars interarticularis of a the vertebra, is best visualized on the oblique radiograph.

94 / Current Therapy in Sports Medicine

thoroughly, and must not be ascribed to a minor back strain or sports injury.
EARLY DETECTION OF SPINAL DEFORMITY

The preparticipation evaluation provides an excellent opportunity for scoliosis screening. Symmetry of shoulder and pelvic heights, balance in the sagittal or coronal plane, and the symmetryof contour betweenthe two sides of the back or lumbar spine are noted. On forward bending, asymmetry of the height of the torso may be a reflection of idiopathic scoliosis, due to the axial rotation of the spine and torso that occurs in addition to the curvature. After limb length discrepancies or other causesof functional spinal curvature have been eliminated, cases of coronal or sagittal decompensation are further evaluated by obtaining standing posteroanterior (PA) and lateral radiographs of the thoracolumbar spine. If these reveal a scoliosiscurvature of less than 15 degrees, or a dorsal kyphosis of more than 50 degrees, we recommend a program of directed exercisesto increase the strength and flexibility of the spine and pelvis. Dorsal extension or asymmetric lateral bend exercisesare also instituted for hyperkyphosis or scoliosis, respectively. It is imperative to continue regular follow-up of any curvature, large or small, becauseof the risk of progression. The child is initially re-evaluated after 3 to 4 months with a repeat clinical examination. If Moire topographic photography is available, comparisonof the initial with the follow-up photograph may help determine any progressionof torso asymmetryassociatedwith scoliosis.If this is not available, the clinical examination can determine whether truncal asymmetry has progressed.If spinal asymmetryappearsto have increased, a repeat radiograph is obtained; a single view (standing posteroanterior for scoliosis or lateral for kyphosis) is sufficient to evaluate for radiographic progressionof the curvature of scoliosis. If this has progressedbeyond 15 degrees, and at least 3 degrees since the previous radiograph, corrective bracing should be instituted.

considered experimental. The techniques being used at present provide obvious advantagesfor the sports-active child. The treatment, which is applied at night, consists of intermittent pulses that stimulate the muscles in the convexity of the curve. During the day, full sports participation continues unhindered. Full-time brace treatment has usually been required to prevent progressionof the curvature. In our clinic, this consists of 23 hours per day of treatment, including use at night, with 1 hour out of the brace to permit bathing and exercising. The sports-active child is allowed to remove the brace during periods of sports participation or practice, for a maximum of 4 additional hours per day, and no ill effects suchas increased rate of progressionor brace failure have been noted. Most children can participate in sports while wearing the low-profile brace, and this includes physical education in school and most recreational sports activities such as bicycle riding, climbing, and running. Most physicians treating juvenile-onset idiopathic scoliosis (in patients aged 6 to 10 years) report a dramatic mechanicalresponseto brace treatment over a period of 3 to 6 months. After this, a part-time bracing regimen is adopted, usually 12 hours per day. Ongoing follow-up is mandatory to determine whether there is loss of correction with this program. We prescribe this part-time bracing program for younger patients with juvenile-onset scoliosis, who must wear the brace until skeletal maturity has been reached, sometimes for 5 to 6 years. This regimen has been successfulin allowing an essentiallynormal lifestyle, while preventing progression of the curvature. In the fully mature athlete, a scoliosiscurve as great as40 to 50 degreesis not a contraindication to full active sports or dance participation (Fig. 4). It is noted that as many as 25% to 30% of serious young amateur or professional dancers in modem dance or ballet have scoliosis curvatures. Despite this, there is no increased incidence of backache or long-term disability in these individuals. When a young, fully mature candidate for dance participation is noted to have a scoliosiscurvature, we obtain a standing posteroanterior radiograph of the

spine to documentthe degree of curvature before

NONOPERATIVE TREATMENT OF SPINAL DEFORMITY Scoliosis In most cases, spinal bracing is the most effective and the most readily available technique for preventing progression of scoliosis.The Milwaukee brace has been encouraging full dance or sports activity, in conjunction with a full back exerciseprogram. A history of menstrual irregularity or menstrual disorder may be present in the young competitive dancer that may contribute to the development of scoliosis and stress fractures in these individuals. Scheuermann's Kyphosis Early detection of Scheuermann's kyphosis is imperative becauseof the dramatic reversalthat mayoccur, if growth remains, as a result of prompt and early bracing techniques. Although scoliosis generally requires bracing until growth ceases,Scheuermann'skyphosis can be treated effectively for 9 to 12 months, with reconstitution of anterior vertebral height and restoration of a relatively normal contour of the spine. A disadvantageof the bracing regimen is that it usually requires a full brace

the standard treatment in North America for the

management of progressive spinal disorders. However, during the past 15 years several different low-profile orthoses have been developed, which appear to manage scoliosis effectively while allowing a significant increase in function. In our experience, these orthoses can adeq~atelyprevent progressionof a scoliosiscurvature if the apex of the curvature is below T9. Electrical muscle stimulation for scoliosis must be

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Figure 4 Mild scoliosis in a skeletally mature adolescent is not a contraindication to full sports participation.

activities should perform prophylactic abdominal strengthening and lumbar flattening exercises, with particular emphasis on the pelvic tilt. Lumbar hyperlordosis increasesthe risk of spondylolysis, and continuous or intermittent hyperlordotic posturing may also predisposeto disc herniation. Therefore, young athletes who perform hyperlordotic maneuvers should also maintain a prophylactic antilordotic exerciseprogram. The young athlete with hyperlordosis and back pain should be completely evaluated for spondylolysis, disc problems, or other etiologic conditions, before the diagnosis of mechanical back pain is made. If exercisesalone do not relieve the back pain, antilordotic bracing should be considered. The response to such bracing is often dramatic, with progressive reposturing of the lumbar spine, resolution of the pain, and concurrent full participation in sports activity. The youngathlete initially wears the antilordotic, low-profile brace during sports activity; when the pain is relieved and the patient remainsasymptomatic during sports participation, the brace can be safelyremoved for sports, but must be worn for the rest of the day. A minimum of 6 months of brace treatment is required to attain satisfactory realignment of the spine. In contrast, brace treatment for spondylolysis is effective only with full-time wearing of the antilordotic, low-profile brace, which flattens and immobilizes the lumbar spine, and therefore relieves pain and promotes healing of the defect (Fig. 5). A concurrent antilordotic strengthening and flexibility exerciseprogram should be maintained, and the bracing program is continued for a minimum of 6 months. Radiographic healing of the pars defect, in addition to resolution of pain, may be observed. When the child becomes asymptomatic and free of pain, and when hamstring flexibility is increased, participation in sports can be safely and effectively resumed, even while the brace is worn. SPINAL FUSION Fusion of the spine may be required in certain cases of severe or progressivespinal deformity such as dorsal roundback and scoliosis. Furthermore, localized fusion may be required for instability due to a previous spinal injury or deformity. The athlete will need recommendations regarding the safety and possibility of returning to sports participation after spinal fusion. Spinal instrumentation, which is commonly used in conjunction with spinal fusion, has improved our ability to straighten the spine and may increase the rate of fusion from sucha procedure (Fig. 6). In somesituations, postoperative external casting or brace support may not be required. Nevertheless, it is generally agreed that establishment of a stable, solid spinal fusion takes approximately 12 months after surgery. Vigorous sports activities that involve twisting, turning, or potential impact to the spine should not be resumed earlier than this. We do allow swimming early in the postoperative period, occasionallyas early as 6 to 8 weeks after spinal fusion, with a protective plastic brace.

with neck ring, especially in the young adult male. The treatment program should include an exercise regimen specificallydirected at restoring strength and flexibility of the lumbar spine and hamstrings.

lumbar Hyperlordosis
Hyperlordotic posturing ("swayback") of the low back may be flexible or fixed. With flexible lumhyperlordosis, forward bending causes the lumbar to flatten and reverse, and there may be no .tightness of the lumbodorsal fascia or ham..The child with this posture is treated with an exercise program and reassessed regular at intervals. .For fixed lumbar hyperlordosis, we institute a dl!ected exercise program of antilordotic strengthening, ":lth lumbodorsal fascia and hamstring flexibility exerCIses. exercisesalone are ineffective, an antilordotic If bracing program is added. <;ertain sports, such as figure skating, gymnastics, and Ice hockey, appear to increase the tendency to develop lumbar hyperlordosis. Participants in these

96 / Current Therapy in Sports Medicine

Figure 6 Extensive spinal fusion with instrumentation is a contraindication to contact sports, but many other sports and fitness activities are allowed.

vigorous sports participation, particularly if this includes active impacting or use of the head and neck. The presence of associatedneurologic symptoms or compromise at the time of the initial injury must also be a factor in the decision regarding continued participation in sports activity.

The athlete who has had lumbosacralfusion is

generally allowed to return to full sports participation, including contact sports, after 1 year, if it is certain that a stable fusion has been attained and there is no neurologic compromise in the lower extremities. In some instances,with newer techniques of localized instrumentation of the fractured pars interarticularis, return to sports participation has been allowed as early as 3 months after fusion, but this is decided on an individual

Figure 5 A thermoplastic low-profile brace used to treat spinal deformities or certain casesof low back pain in young

athletes.

basis.

A child or adolescent who has had spinal instrumentation and fusion of more than two segmentsof the spine should be strongly counseled againstparticipation in high-impact sports such as gridiron football or rugby, even after solid fusion has been established. However, moderate contact sports such as basketball, soccer, or field lacrosse are generally allowed. In the case of more localized fusion, such as single-level fusion of the cervical spine for antecedent trauma, or fusion across the lumbosacral junction for spondylolysis,the return to sports participation must be individualized. With any spine fusion, there is an increased risk of long-term problems due to deterioration of the spinal elements immediately above or below the area of fusion. This deterioration may be hastenedby

SUGGESTED READING
Micheli U. Low back pain in the adolescent: differential diagnosis.Am J Sports Med 1979; 7:362-364. Micheli U. Back injuries in dancers. Clin Sports Med 1983;2:473-484. Micheli U. Sports following spinal surgery in the young athlete. Clin Orthop 1985; 198:152-157. Micheli U. The use of the modified Boston brace system(B.O.B.) for back pain: clinical indications. Orthot Prosthet 1985;39:41-46. Micheli U, Hall JE, Miller ME. Use of modified Boston brace for back injuries in athletes. Am J Sports Med 1980; 8:351-356. Stanish W. Low back pain in athletes: an overuse syndrome. Clin Sports Med 1987; 6:321-344. Winter RB. Spinal problems in pediatric orthopaedics. In: Lovell WW, Winter RB, eds. Pediatric orthopaedics. 2nd Ed. Philadelphia: JB Lippincott, 1986:569.