Pediatric Spine Deformities

Spine Deformity Basics - Initial Twists

• Core Deformities & Planes:
  • Scoliosis: Lateral bend + vertebral rotation (Coronal plane).
  • Kyphosis: Posterior "hunchback" curve (Sagittal plane).
  • Lordosis: Anterior "swayback" curve (Sagittal plane).
• Scoliosis Specifics:
  • Cobb Angle: > 10° for diagnosis.
  • Vertebral Rotation ("Twist"): Key to structural scoliosis. Differentiates from flexible, non-structural curves.
• Kyphosis Threshold:
  • Normal Thoracic: 20-45°.
  • Hyperkyphosis: > 50°.
• Common Etiologies: Idiopathic (most frequent), Congenital (vertebral anomalies), Neuromuscular (muscle imbalance).

⭐ Adam's Forward Bend Test helps detect the rotational component (rib hump) in scoliosis, indicating a structural curve.

Idiopathic Scoliosis - Curve Control

• AIS: Most common; >10 yrs. Screen: Adam's Test, Scoliometer (>5-7° → X-ray).
• Cobb Angle: Measures curve on X-rays.
• Risser Sign: Iliac apophysis (0-5); skeletal maturity. Treatment guide.
• Goals: Halt progression, balance, prevent lung issues.

⭐ Bracing in AIS is primarily for skeletally immature patients (Risser 0, 1, 2) with curves 25-45° to halt progression; it does not correct the existing curve.

Kyphosis & Spondylolisthesis - Sagittal Slips

Kyphosis: Excessive posterior thoracic curvature.

• Postural: Flexible; corrects with hyperextension.
• Scheuermann's: Rigid; thoracic kyphosis >45°.
  • Criteria: Wedging >5° (≥3 vertebrae), Schmorl's nodes, irregular endplates.
  • Rx: Brace (45-75°, immature); Surgery (>75° or neuro).
• Congenital: Vertebral anomaly; high neuro risk. Early surgery.

Spondylolisthesis: Anterior vertebral slip, commonly L5-S1.

• Isthmic (Type II): Common in adolescents; pars defect (spondylolysis).
  • 📌 "Scottie dog" sign on oblique X-ray for pars defect.
• Meyerding Grades (% slip): I (0-25), II (26-50), III (51-75), IV (76-100), V (>100).
• Clinical: LBP, tight hamstrings, "step-off".
• Rx: Conservative (low grade). Surgery (high grade/progressive/symptomatic).

⭐ In children, high-grade spondylolisthesis (Grade III+) has a higher risk of progression and neurologic compromise.

Congenital & NM Scoliosis - Complex Curves

• Congenital Scoliosis:
  • Etiology: Vertebral anomalies - failure of formation (e.g., hemivertebra, wedge vertebra) or failure of segmentation (e.g., unsegmented bar, block vertebra).
  • Progression: High risk, especially with unilateral unsegmented bar + contralateral hemivertebra (up to 75% progress).
  • Associated: VACTERL, Klippel-Feil syndrome, intraspinal anomalies (e.g., diastematomyelia - MRI essential pre-op).
  • Curve: Often rigid, sharp, angular.
• Neuromuscular (NM) Scoliosis:
  • Etiology: Cerebral palsy (most common), Duchenne muscular dystrophy, SMA, myelomeningocele.
  • Curve: Long, sweeping "C"-shaped curves; often associated with significant pelvic obliquity.
  • Progression: Rapid, especially in non-ambulatory patients; continues after skeletal maturity.
  • Pulmonary function compromise is common.
• Management (Complex Curves):
  • Observation: Curves < 25°.
  • Bracing: Limited efficacy in congenital; may delay surgery in some NM scoliosis (e.g., to allow lung maturation), but often poorly tolerated.
  • Surgery: Indicated for progressive curves > 50°. Options include growing rods (e.g., VEPTR, magnetically controlled), spinal fusion, hemivertebra excision.
    • Goals: Prevent progression, improve sitting balance, preserve/improve pulmonary function.

⭐ In neuromuscular scoliosis, pelvic obliquity is a critical component; failure to address it during spinal fusion can lead to persistent sitting imbalance and pressure sores.

High‑Yield Points - ⚡ Biggest Takeaways

• Scoliosis: Cobb angle >10°. Screen with Adam's forward bend test. AIS is most common.
• AIS: Risser sign for maturity. Brace 25-45° (immature). Surgery for curves >45-50°.
• Congenital Scoliosis: Due to vertebral anomalies (hemivertebrae). High risk of progression.
• Neuromuscular Scoliosis: In CP, DMD. Often progressive, requires early surgery.
• Scheuermann's Kyphosis: Rigid thoracic kyphosis; anterior wedging ≥5° (≥3 vertebrae); Schmorl's nodes.
• Spondylolisthesis: Isthmic type (L5-S1 pars defect) common. Use Meyerding grading.