Juvenile scoliosis

Introduction

Juvenile scoliosis is a complex orthopedic condition that affects the curvature of the spine in children and adolescents. It is characterized by an abnormal lateral curvature of the spine, often associated with rotation of the vertebrae, which gives the spine an “S” or “C” shape. This condition can have significant implications for a child’s growth and development, requiring early and often prolonged intervention to avoid long-term complications.

Juvenile scoliosis typically begins between the ages of 4 and 10 years, although earlier or later cases can also occur. Curve progression can be rapid during rapid growth phases, making regular screening crucial in children, especially those with a family history of scoliosis.

The exact causes of juvenile scoliosis are not fully understood, but they may include genetic factors, muscle abnormalities, or neurological problems. Some forms of juvenile scoliosis may be associated with underlying medical conditions such as Marfan syndrome or cerebral palsy.

Management of juvenile scoliosis varies depending on the severity of the curve and the age of the child. For mild to moderate curves, conservative approaches such as regular observation, physical therapy, and the use of braces may be recommended to control the progression of the curve during growth. In more severe or progressive cases, surgery may be necessary to correct the curve and stabilize the spine.

Juvenile Scoliosis: An Overview

The Origins of Juvenile Scoliosis

Juvenile scoliosis is often classified according to the age of onset. It can occur in children between the ages of 3 and 10 (early juvenile scoliosis) or between the ages of 10 and 18 (late juvenile scoliosis). In most cases, the exact cause remains unknown, leading to the classification as idiopathic.

Genetic factors appear to play a predominant role in the development of juvenile idiopathic scoliosis. Studies have identified specific genes that may be associated with susceptibility to this condition. However, other factors, such as congenital anomalies or neuromuscular disorders, may also contribute to the development of scoliosis in some children.

Diagnosis and Evaluation

Early diagnosis of juvenile scoliosis is essential for effective management. Health professionals use a variety of methods, including physical examination, medical imaging, and the Adam’s forward bend test, which assesses the curvature of the spine when leaning forward.

The use of radiography allows measurement of the Cobb angle, which quantifies the severity of the curve. This assessment often guides treatment decisions, especially if the curve continues to progress.

Therapeutic Approaches Throughout History

The Milwaukee Corset (1940s-1960s)

In the early decades of the 20th century, the primary treatment for juvenile scoliosis was the Milwaukee brace. This orthopedic device was designed to hold the spine in a corrected position. Although widely used, the Milwaukee brace had limitations in terms of comfort and social acceptance.

The Age of Surgery (1970s-1990s)

The 1970s saw the emergence of more advanced surgical techniques to treat juvenile scoliosis, particularly for severe curvatures. Surgical procedures, such as spinal fusion with instrumentation, were developed to stabilize the spine and correct deformities. However, these procedures were not without risks, and improvements in techniques continued over time.

Conservative Approaches and Physiotherapy (1990s to Present)

In recent decades, increased attention has been paid to conservative approaches for juvenile scoliosis. Physiotherapy and rehabilitation play a vital role in the management of scoliosis. Specific exercises aim to strengthen the trunk muscles and improve posture. These approaches have the advantage of being less invasive than surgery and can help improve patients’ quality of life.

Technological Advances (Today)

With the advent of modern technologies, innovative approaches have emerged for the treatment of juvenile scoliosis. Computer simulation and 3D printing are used to design more comfortable and personalized corsets, offering a more attractive alternative to traditional methods.

Causes of Juvenile Scoliosis

1. Idiopathic:
   • The most common cause of juvenile scoliosis is idiopathic, meaning that no specific cause is identified. Juvenile idiopathic scoliosis is often diagnosed between the ages of 4 and 10 years.
2. Congenital:
   • Juvenile scoliosis can result from congenital spinal malformations present at birth. These abnormalities can influence the normal development of the spine.
3. Neuromuscular:
   • Neuromuscular disorders, such as muscular dystrophy, cerebral palsy, or polio, can cause muscle weakness or imbalance, contributing to the development of scoliosis.
4. Genetic Syndromes:
   • Certain genetic syndromes, such as Marfan syndrome, Prader-Willi syndrome, or Noonan syndrome, are associated with an increased risk of developing scoliosis.
5. Tumors :
   • Although rare, spinal tumors can also cause scoliosis in children.
6. Infections :
   • Spinal infections, although uncommon, can cause structural changes in the spine, leading to scoliosis.
7. Environmental factors :
   • Certain environmental factors may contribute to the development of scoliosis, although their specific role is not always clear. Factors such as prolonged sitting, improper carrying of backpacks, or inequalities in leg length have been suggested.

It is essential to emphasize that in many cases the cause of juvenile scoliosis remains unknown (idiopathic). Juvenile idiopathic scoliosis is often diagnosed after excluding other identifiable causes. Accurately diagnosing the cause of scoliosis and determining its appropriate treatment requires a thorough evaluation by a healthcare professional, particularly an orthopedist who specializes in spinal disorders.

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Symptoms of Juvenile Scoliosis

Symptoms can vary depending on the severity of the curve, the underlying cause, and other factors. Here are some common symptoms of juvenile scoliosis:

1. Postural Asymmetry:
   • A visible tilt or asymmetry of the shoulders may be observed, with one appearing higher than the other.
2. Pelvic Tilt:
   • The pelvis can also be tilted, creating an asymmetry at the waist.
3. Asymmetry of the shoulder blades:
   • One shoulder blade may appear more prominent or higher than the other.
4. Possible Chest Deformation:
   • In some cases, scoliosis can cause a deformation of the rib cage, which may be noticeable.
5. Respiratory Problems:
   • Severe scoliosis can compress the lungs, leading to breathing problems such as reduced lung capacity.
6. Back pain :
   • Some children may experience back pain, especially during the rapid growth of adolescence.
7. Early Fatigue:
   • Due to the deformation of the spine, the muscles may work inefficiently, leading to premature fatigue during physical activities.
8. Clothes that don’t fit properly:
   • Clothing that doesn’t fit properly or appears unbalanced can be an indirect sign of scoliosis.
9. Possible Respiratory Discomfort:
   • In severe cases, where scoliosis affects lung capacity, symptoms such as breathing discomfort may occur.

It is important to note that juvenile scoliosis may be asymptomatic in its early stages, and symptoms may not become apparent until the curve progresses. Early detection, usually done during routine exams, is crucial for effective scoliosis management. If signs of scoliosis are observed, it is recommended to consult a healthcare professional, often an orthopedist, for a thorough evaluation and an appropriate treatment plan.

Screening for Juvenile Scoliosis

1. Visual Examination:
   • During routine school or pediatrician checkups, a visual examination of the spine is often performed. The child may be asked to lean forward, which allows the health care professional to spot any asymmetries or deformities.
2. Standing Position Exam:
   • The child may also be examined in a standing position to detect any asymmetry in the shoulders, waist, or shoulder blades.
3. Trunk Angle Measurement:
   • Some health professionals use trunk angle measuring tools to quantify any spinal tilt.
4. Assessment of Shoulder and Waist Asymmetry:
   • Assessing shoulder and waist asymmetry is also a common method to spot possible signs of scoliosis.
5. Reflection on Family History:
   • Family history may play a role in screening, as scoliosis sometimes has genetic components. If a family member has been diagnosed with scoliosis, this may prompt closer monitoring.
6. Imaging tests (if necessary):
   • If there is any doubt or signs of scoliosis are observed, imaging tests such as spinal X-rays may be performed to confirm the diagnosis and assess the severity of the curve.

It is important to emphasize that screening for juvenile scoliosis should be done regularly throughout a child’s growth, as progression of the curve may be more rapid during growth spurts. If scoliosis is detected, regular follow-up is often recommended to monitor its progress. In some cases, interventions such as bracing or surgery may be considered to prevent severe progression. Close follow-up with a healthcare professional, usually an orthopedist who specializes in spinal disorders, is essential for effective screening and management of juvenile scoliosis.

Adam’s Forward Bend Test

The Adam’s Forward Bend Test is a clinical assessment commonly used to detect the presence of scoliosis. It is named after Dr. Robert Adams, an 18th-century physician who contributed to the understanding of scoliosis. Here’s how the test is typically performed:

1. Patient Positioning:
   • The patient stands with his feet together and his knees slightly bent. The feet should be parallel and the arms relaxed at the sides of the body.
2. Forward Tilt:
   • The patient is asked to slowly lean forward from the waist, so that the back is parallel to the floor. The arms are left hanging freely.
3. Observation Visual :
   • The healthcare professional observes the patient’s back during the tilt. He or she looks for signs of asymmetry, such as uneven shoulders or shoulder blades, a difference in hip height, or an abnormal curvature of the spine.
4. Deviation Measurement:
   • Using an inclinometer or simply by visually estimating, the professional measures the angle of deviation between the right and left sides of the back. This angle is often called the angle of gibbosity or inclination.
5. Examination of the Touchable Vertebrae:
   • During flexion, the professional can also feel the protruding vertebrae by running the hands along the back to determine the location of the curvature.

Radiographic Signs of Juvinile Scoliosis

Radiographic signs of juvenile scoliosis are assessed using X-rays of the spine. X-rays provide detailed information about the curvature of the spine, allowing healthcare professionals to measure the Cobb angle and determine other characteristics of scoliosis. Here are some common radiographic signs of juvenile scoliosis:

1. Angle de Cobb :
   • The Cobb angle is the primary measure of scoliosis severity. It is determined by measuring the angle formed by the most inclined vertebrae in the curvatures of the spine.
2. Location of the Curvature:
   • X-rays show the specific location of the curve, whether in the thoracic, lumbar, or thoracolumbar region. This information is crucial for treatment planning.
3. Assessment of Touchable Vertebrae (Extremity Vertebrae):
   • The end vertebrae of the curvatures are identified to determine the vertebrae most involved in the spinal deviation.
4. Vertebral Rotation:
   • X-rays may reveal spinal rotation, a characteristic feature of some scoliosis, where the vertebrae rotate around their longitudinal axis.
5. Length of the Curves:
   • The length of the curvatures can be measured to assess the distribution of deformity over the spine.
6. Intervertebral Disc Assessment:
   • X-rays also help assess the condition of the intervertebral discs, facet joints and other anatomical structures.
7. Identification of Congenital or Structural Anomalies:
   • X-rays can reveal congenital or structural abnormalities that could contribute to juvenile scoliosis.
8. Growth Monitoring:
   • Sequential X-rays over time help monitor the growth and progression of scoliosis, especially during phases of rapid growth.

King-Moe Classification of Juvenile Scoliosis

1. Type I: Infantile Scoliosis (0-3 years)
   • This category concerns cases of scoliosis that develop in children aged 0 to 3 years.
   • Infantile scoliosis can be congenital, neuromuscular, idiopathic, or due to spinal abnormalities.
2. Type II: Juvenile Scoliosis (4-10 years)
   • Juvenile scoliosis affects children between the ages of 4 and 10.
   • It can also be congenital, neuromuscular, idiopathic or linked to vertebral anomalies.
3. Type III: Adolescent Scoliosis (11-18 years)
   • Adolescent scoliosis occurs in individuals between the ages of 11 and 18.
   • It is mainly idiopathic, meaning that no specific cause is identified in the majority of cases.
4. Type IV: Adult Scoliosis (after 18 years)
   • Adult scoliosis occurs after the age of 18.
   • It can be idiopathic, degenerative (related to aging), or result from the progression of scoliosis already present in adolescence.

Angle de Cobb

The Cobb angle is a radiographic measurement used to quantify the angular deviation of the spine in scoliosis. This measurement is essential for assessing the severity of the curve and for tracking the progression of scoliosis over time. Here’s how the Cobb angle is determined:

1. Identification of Limit Vertebrae:
   • On an X-ray of the spine, the upper and lower border vertebrae of the scoliotic curvature are identified.
2. Perpendicular Lines:
   • From the upper and lower edges of these boundary vertebrae, perpendicular lines are drawn.
3. Intersection of Lines:
   • The angle formed by the intersection of these two perpendicular lines is measured. This angle is the Cobb angle.
4. Severity Assessment:
   • The Cobb angle is used to assess the severity of scoliosis. By convention, scoliosis is classified as mild if the angle is less than 25 degrees, moderate between 25 and 40 degrees, and severe if the angle is greater than 40 degrees.

The management of juvenile scoliosis requires a multidisciplinary approach, involving health professionals such as orthopedists, osteopaths and sometimes surgeons. Recommendations and future perspectives aim to improve early diagnosis, optimize treatment modalities and explore new therapeutic avenues.

Current Recommendations

1. Early Detection: School and pediatric screening programs play a critical role in the early detection of scoliosis. Early diagnosis allows for noninvasive interventions and monitoring of the curve as it progresses during growth.
2. Regular Follow-up: Regular follow-up with specialized health professionals is recommended to assess the progression of scoliosis and adjust the treatment plan accordingly. The frequency of visits depends on the severity of the curve and the child’s growth.
3. Early Interventions: Early interventions, such as physical therapy and rehabilitation, are often preferred for moderate curves. These approaches can help strengthen core muscles, improve posture, and reduce the risk of progression.
4. Personalized Treatment Options: The choice of treatment depends on several factors, including the severity of the scoliosis, the child’s age, and their expected growth. Braces may be prescribed for some curvatures, while surgery may be considered for more severe cases.
5. Education and Support: Education of patients and their families is crucial to promote a better understanding of scoliosis and its treatment. Psychological support can also be beneficial, especially for adolescents living with this condition.

Futures Perspectives

1. Innovative Technologies: The use of modern technologies, such as virtual reality and artificial intelligence, could open new perspectives for home monitoring, posture tracking and personalization of treatment plans.
2. Genetic Research: Advances in genetic research could lead to a better understanding of the genetic factors associated with juvenile scoliosis. This could eventually lead to more targeted therapeutic approaches.
3. Gene Therapies: Although still in the research stage, gene therapies could eventually offer innovative solutions for treating juvenile scoliosis by acting directly on the genes involved in its development.
4. Personalized Approaches: Personalized medicine could become a reality for juvenile scoliosis, with treatment plans tailored to each patient’s specific genetic, physiological and anatomical characteristics.

In conclusion, the management of juvenile scoliosis has evolved considerably over time, offering today more varied and personalized treatment options. Current recommendations emphasize early detection, non-invasive interventions and regular follow-up, while future perspectives are oriented towards innovative approaches based on genetic research and technological advances. The ultimate goal is to improve the quality of life of children and adolescents with juvenile scoliosis.