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By

Andhika Amran
C 111 08 806

Advisors
dr. Alfa
dr. Victor

Supervisor
dr. Jenal Arifin, Sp.OT (K) Spine
Orthopaedic and Traumatology Department
Hasanuddin University
2016

PATIENT IDENTITY

Name
Age
Sex
RM

:F
: 15 years old
: Female
: Date of admission:

HISTORY TAKING

Chief complaint: deformity of the back

Suffered since 1 year before admitted to the hospital and


getting worsen every month in the past one year
Additional complaint :pain in the back of the body,
suffered since 3 months before admitted to the hospital. Pain is
intermitten and become worst if doing some heavy activity.
Urinary and defecation are normal

History:
History of birth was normally without any difficulties, got help by
midwife.
History of milestone is normal
History of menarche at 13 years old, the menarche period and
cycle are normal
History of trauma (-)
History of bone setter (+)
Family History of scoliosis (-)

GENERAL STATUS
Poor nourished/consciouss
Vital Sign
BP
: 110/60 mmHg
HR
: 72 bpm, regular
RR
: 18 tpm
Temp. : 36.7C

LOCAL STATUS
Vertebra Region :
I: deformity of the spine with right curvature,
asymetrical shoulder, prominent right
scapula, asymetrical waist , gibbus (-), caf au
lai spot (-)
P: tenderness (-)

CLINICAL PICTURE

5
5
5
5
5

5
5
0
5
5
5

5
5
5
5
5

5
5
5
5
5

Motoric
Examination

yes

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

Any anal sensation


0 Absent
1 Impaired
2 Normal
NT Not testable

Reflex
Physiologic Reflex

Biceps
(+)
Triceps (+)
Achilles (+)
Patellar (+)

R
(+)
(+)
(+)
(+)

Pathologic Reflex

Babinski
Chadock
Openheim
Hoffman
Tromner

R
(-)
(-)
(-)
(-)
(-)

L
(-)
(-)
(-)
(-)
(-)

LABORATORY FINDINGS
WBC

8.600 /uL

RBC

4.810.000 /uL

HGB

10,6 g/dl

HCT

31.0%

PLT

317.000/uL

Ureum

12 mg/dl

Creatinin

0,4 mg/dl

GDS

75 mg/dl

SGOT

21 U/L

SGPT

22U/L

HBsAg(rapid)

negative

CT

930

BT

230

LED I
LED II

23 mm
48 mm

Radiology Findings

25o

10o

Proximal Thoracic Curve

50o

50o

Main Thoracic Curve

22o
25o

Lumbar Curve

8o

CSVL

Thoracic Sagital

Lenkes Classification

PELVIS AP, Risser's sign 4

Thorax X-Ray

CT-Scan

CT-Scan

DIAGNOSIS
Adolescent Idiopathic Scoliosis
Lenkes Classification Type 3 A -

TREATMENT
Analgesic
Surgery Planning

RESUME
A 15 years old girl, with chief complaint deformity of the back
suffered since 1 year before admitted to the hospital and getting
worsen every month for this past one year. She also suffered
pain in the back of the body since 3 months ago. Pain is
intermitten and become worst if doing some heavy activity.
History of trauma (-) , history of bone setter (+), History of
milestone is normal.
Physical examination found deformity of the spine with right
curvature, asymetrical shoulder, prominent right scapula,
asymetrical waist. Sensoric, motoric, and reflex are normal
Radiography shows is lenkes classification type :3 A -

Discussion
IDIOPATHIC ADOLESCENT
SCOLIOSIS

Description
Three-dimentional deformity of the spine with lateral
curvature plus rotation of the vertebral bodies, sagital
coronal and axial
It is defined as a curve >10 as measured by cobb
method

Devlin, V.J. Spine Secrets. USA: Hanley & Belfus, INC. An Affiliate of Elsevier ;2002.

Frassica, F.J.; D. Sponseller, P.D.; Wilckens, J.H.5-Minute Orthopaedic Consult, 2nd


Edition. UK: Lippincott Williams & Wilkins.;2007.

Etiology
The cause is the focus ongoing research. Areas under
investigation include:
Genetics factors: due to the higher incidence of scoliosis within
families compared to general population
CNS factors :CNS Asymmetry, vestibular dysfunction
Collagen, muscle, and platelet defects
Growth and hormonal factors: asymmetry spinal growth
patterns, melatonin
Biomechanical factors
Devlin, V.J. Spine Secrets. USA: Hanley & Belfus, INC. An Affiliate of Elsevier ;2002.

CLASSIFICATION
(Etiology)

IDIOPATHIC SCOLIOSIS

According to the age of onset:

Infantile (0-3 yr)


Juvenile (3-10 yr)
Adolescent (>10yr)

Devlin, V.J. Spine Secrets. USA: Hanley & Belfus, INC. An Affiliate of Elsevier ;2002.

Initial Evaluation

Physical Examination
Inspection of skin
Caf au lait spots (Birth
mark)

Shoulder height
Arm trunk space
Scapular position
Trunk shift
Iliac crest height
Leg length discrepancy

Adams Test

Plumb line

IMAGING
Plain Xray:
(AP/Lateral)

At least from T1 L5
should be seen clearly
Force side bending R
&L

Curve type
Cobb's angle

Cobbs Angle
Assessed :
1.End Vertebrae
2.Apical
3.Curve Location
4.Curve direction
5.Curve magnitude
6.Risser Sign
7.Structural curve
8.Nonstructural curve
9.Major curve
10.Minor Curve
11.Rotation

Radiology
End Vertebra : The top and bottom
vertebrae that tilt maximally into
concavity of the curve, they are typically
least rotated, least horizontally displaced
vertebra within a curve
Apical vertebra : the central vertebra
within the curve its typically the least
tilted, most rotated, and most horizontally
displace

Radiology
Curve location: curve location its
defined by its apex
Curve
Apex
CervicoThoraxic
C7 T1
Thoraxic
T2 T11
Thoracolumbal
T12 L1
Lumbar
L2 L4
Lumbosacral
L5 S1

Radiology
Curve Direction : it was determined
by the side of convexity, curve
convex toward to the right are
termed right curve
Curve magnitude : using cobb
lippman technique : the angle
formed by the intersection of the
two line that are drawn across the
superior end plate of the upper end
vertebra and the inferior endplate of
the lower end vertebra

RISSERS SIGN
Risser Sign describes the
ossification of the illiac epiphysis
Grade 0 : absent
Grade 1 : (0-25%)
Grade 2 : (26-50%)
Grade 3 : (51-75%)
Grade 4 : (76-100%)
Grade 5 : fusion of epiphysis of
illium
Grade 4 is correlate with the end of
spinal growth
Grade 5 is correlates with the end of
height increase

Rotation (Nash-Moe Classification)


Pedicle position

Lenkes Classification

Treatment
Goal :
To prevent progression
Correction trunkal Balance
Improve quality of live
Safe correction
Treatment options (Three O)
Observation & re-evaluate
Orthoses
Operation

Observation
- Curve < 25o, Immature
- curve < 40o , Mature
Ro 3 mo after first visit, then 6 mo for < 20o &
4 6 mo for > 20o
significant change :
- progression > 10o for curve < 20o and
- progression > 5o for curve > 20o

Orthosis (Bracing)

Only stop progression, not reduce


Curve 20-29o, premenarchal, Risser stage 0-1
Curve 30 40o, skeletally immature should be brace
immadiatelly

use principle:
o
Must be wear 23 hours
o
2 years after risser 4
o
wean off in year

Milwaukee Brace

Effective for curve


correction 40 - 50
CTLSO : apex above T8
Contraindication for old
people
Must be combained
with excercise

Boston Brace

For correction lumbal


curve
TLSO : apex below T8
Effective for correct
curve 40 - 45

Operation
Indication
Curve > 40o, immature adolescent
Curve > 50o, mature adolescent
Curve > 30o, with thoracic lordosis

Complications
Severe curves (>70) occasionally may progress
to the point where they compromise pulmonary
function.
Curves >40 pose an increased risk of back pain
in adulthood
Surgical complications include neurologic injury
(<1%), infection, and failure of the vertebrae to
fuse
Frassica, F.J.; D. Sponseller, P.D.; Wilckens, J.H.5-Minute Orthopaedic
Consult, 2nd Edition. UK: Lippincott Williams & Wilkins.;2007.

Prognosis
Pulmonary compromise, including cor pulmonale
in congenital or neuromuscular curves, occurs
mainly in patients with curves >100
Most untreated curves >40-50 in adulthood
slowly become worse

Frassica, F.J.; D. Sponseller, P.D.; Wilckens, J.H.5-Minute Orthopaedic Consult,


2nd Edition. UK: Lippincott Williams & Wilkins.;2007.

Thank You