import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Spine Scoliosis Examination Scoliosis examination requires systematic assessment of the spinal deformity and exclusion of non-idiopathic causes. Examiners expect you to perform the Adams forward bend test correctly, measure trunk rotation, assess skeletal maturity (Risser sign), and recognize red flags suggesting underlying pathology. ## Quick Reference One-Pager ## Types of Scoliosis **By Etiology:** - **Idiopathic** (80%): Most common, diagnosis of exclusion - Infantile: 0-3 years - Juvenile: 4-10 years - Adolescent (AIS): 10+ years to skeletal maturity - **Congenital**: Vertebral anomalies (hemivertebra, bar) - **Neuromuscular**: CP, muscular dystrophy, SMA - **Syndromic**: Neurofibromatosis, Marfan, Ehlers-Danlos **Curve Classification:** - Location: Cervical, thoracic, thoracolumbar, lumbar - Direction: Named by convexity (e.g., "right thoracic") - Structural vs Non-structural: Structural has rib rotation **Adolescent Idiopathic Scoliosis (AIS):** - Most common type (80% of scoliosis) - Female:Male = 7:1 for curves requiring treatment - Typical pattern: Right thoracic curve - Age of onset: 10-18 years (skeletal maturity) - Diagnosis of EXCLUSION - must rule out other causes ## Physical Examination ### Observation **With patient in underwear, standing relaxed:** 1. **Head Position**: Should be centered over pelvis 2. **Shoulder Height**: Asymmetry common 3. **Scapulae**: Prominence, winging, asymmetric position 4. **Trunk Shift**: Trunk displaced relative to pelvis 5. **Waist Creases**: Asymmetric (deeper on concave side) 6. **Pelvis**: Level or oblique 7. **Gluteal Creases**: Level or asymmetric 8. **Leg Length**: Compare PSIS levels **Plumb Line Assessment:** - Drop line from C7 spinous process - Should fall through gluteal cleft - Deviation indicates coronal imbalance **Sagittal Profile:** 1. **Cervical Lordosis**: Normal 2. **Thoracic Kyphosis**: Normal 20-40° (increased = hyperkyphosis) 3. **Lumbar Lordosis**: Normal 40-60° 4. **Sagittal Balance**: C7 plumb over S1 5. **Pelvic Tilt**: Note pelvic version **Common Finding in AIS:** - Hypokyphosis (flat back) is common in thoracic curves - May have thoracolumbar kyphosis ### Adams Forward Bend Test **Adams Test Interpretation:** - **Rib Hump**: Convex thoracic curve causes ribs to rotate posteriorly - **Lumbar Prominence**: Convex lumbar curve causes paravertebral muscle bulge - **No Prominence on Bending**: Suggests postural/non-structural scoliosis - **Measure with Scoliometer**: Place across back at apex; 5-7° or more = significant ### Specific Assessments ## Red Flags for Non-Idiopathic Scoliosis **Red Flags Requiring Investigation:** - Age less than 10 years (juvenile or infantile) - Male patient (AIS rare in males) - Left thoracic curve (atypical pattern) - Rapid progression (greater than 10° in 6 months) - Pain (especially night pain, constant) - Neurological abnormalities - Café-au-lait spots (neurofibromatosis) - Foot deformity (cavovarus suggests CMT or spinal dysraphism) - Skin stigmata over spine (dimple, hairy patch) - Absent abdominal reflexes (syringomyelia) **If ANY red flags → MRI spine BEFORE treatment decisions** ## Maturity Assessment **Importance:** - Curve progression risk highest during growth spurt - Immature skeleton = higher progression risk - Maturity affects treatment decisions **Methods:** | Measure | Description | |---------|-------------| | **Risser Sign** | Iliac apophysis ossification (0-5 on X-ray) | | **Menarche** | Peak height velocity 6-12 months before menarche | | **Tanner Stage** | Sexual maturity rating | | **Triradiate Cartilage** | Open = significant growth remaining | | **Sanders Stage** | Hand X-ray classification (1-8) | **Risser Sign:** - 0: No ossification (high risk) - 1: Up to 25% ossification - 2: 25-50% - 3: 50-75% - 4: 75-100% - 5: Fused to ilium (skeletal maturity) ## Curve Progression Risk ## Associated Assessments **Always Include:** 1. **Skin Examination:** - Café-au-lait spots (6 or more spots plus 15mm = NF1) - Sacral dimple, hairy patch (spinal dysraphism) - Axillary freckling (NF1) 2. **Upper Limb:** - Marfan features (arachnodactyly, thumb sign, wrist sign) - Joint hypermobility (Ehlers-Danlos) 3. **Cardiac:** - Marfan syndrome = check for murmur (aortic) 4. **Eyes:** - Marfan = lens subluxation - NF1 = Lisch nodules ## Summary Presentation ## Differential Diagnosis ## Examiner Tips