SPINE PATH

Your support in evaluation of idiopathic scoliosis

SPINE PATH PROJECT

The Spine-Path procedure has been developed to help clinicians dealing with adolescents affected by idiopathic scoliosis during their evaluation and clinical decision-making process. This document is meant to help, not to replace, the clinician’s analysis. The procedure has to be a guide and not a diagnostic device used without a specific clinician’s evaluation. The Spine-Path procedure has been specifically developed for children and adolescents aged 9-15 with suspected scoliosis. Although idiopathic scoliosis is the most common type of spine deformity, its diagnosis is still made by exclusion.

PATIENT CARD

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THE PROCEDURE

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PROCEDURE

Who is Spine Path for?

The Spine-Path procedure has been developed to help clinicians dealing with adolescents affected by idiopathic scoliosis during their evaluation and clinical decision-making process.

The Spine-Path procedure has been specifically developed for children and adolescents aged 9-15 with suspected scoliosis.

Although idiopathic scoliosis is the most common type of spine deformity, its diagnosis is still made by exclusion. The first medical examination of an adolescent with suspected scoliosis consists of a detailed personal and family medical history, a physical examination to exclude associated symptoms or other underlying conditions, the spine alignment and mobility evaluation on all planes, the collection of any auxological information at disposal.

CLINICAL TIPS

Aim and limits of the procedure

 

During the medical examination boys should wear only their pants whereas girls should wear only their bra and underwear. The examination usually starts observing the patient standing with parallel feet. The clinician looks for asymmetries on the frontal plane observing shoulder, hip, head and spine alignment. The above mentioned elements are important to complete the clinical examination but are of uncertain clinical interpretation.

If spine asymmetries are noticed, the clinician has to verify whether the patient is affected by scoliosis or functional scoliosis asking the patient to bend forward and noticing if trunk asymmetries or any abnormal spinal curvatures are present. The spine evaluation always includes the observation of dorsal kyphosis and lumbar lordosis on the sagittal plane. Their degree can be easily quantified using an arcometer but the present algorithm does not include any specific cut-off value for them. Sometimes, however, they play an important role during the clinical decision-making process.

Spine rotation is the main element which differentiates functional scoliosis (no trunk rotation during flexion) from structural scoliosis. The clinician usually asks the patient to perform the Adam’s forward bending test to investigate the presence of spine abnormalities.

The patient bends forward dangling the arms, with the feet together and knees straight. Asymmetries highlighted by the test, however, may be due to difficulties keeping knees straight or because one leg may be shorter than the other. Limb length discrepancies can be evaluated with the patient standing on their feet and placing blocks under the shorter foot or using the delta-leg device having the patient supine. The patient can also be evaluated in the sitting position, with hips and knees at 90 degrees of flexion, in case all previous measurements were considered of uncertain interpretation.

Leg length discrepancies are often associated to asymmetries of spine alignment in standing position. In such cases, LLD alone, when compensating the difference in height with a lift or when evaluating the patient in the sitting position, the spine usually looks aligned and no trunk rotations are noticed while the patient bends forward.

Leg length discrepancies can be measured in different ways:

  • measurements using blocks: the clinician places some boards under the foot of the shorter leg and asks the patient to bend forward. Boards are added until the hips look aligned while the patient performs the forward bending movement. The alignment can be verified using the inclinometer;
  • the Delta-leg measuring device: the instrument quantifies leg length discrepancies having the patient in supine position;
  • measurement with a tape: the clinician measures the limb length between two defined points which are the anterior iliac spine and the medial or lateral malleolus. Measuring limb length with the tape is a widely used practice but far less precise compared to the two previously described methods.

The spine rotation is commonly measured with the inclinometer or with the scoliometer and is expressed in degrees. The amount of rotation is quantified while the patient is standing, bending the trunk forward with arms dangling, or having the patient in the sitting position with the trunk bending forward. The latter position is particularly suggested in case of leg length discrepancies or in case of hamstring retraction which does not allow the complete forward bending movement of the trunk.

The inclinometer used in this centre is a validated instrument which can precisely measure the angle of trunk rotation during the forward bending test and the Cobb-angle on radiographs.

Growth velocity curve may not be available during the first visit but parents can be asked to provide it since paediatricians usually keep their records up to date. Should growth velocity not be available, the patient height can be compared with that of their parents. A detailed medical history can then help identifying a recent or past growth spurt. Secondary sex characteristics should be taken into account during the examination.

Girls should be asked if they have already had their menarche by the time of the visit and, possibly, its date. Menarche usually occurs towards the end of the growth spurt although its time can vary a lot. Even the foot growth rate can be of interest since its spurt is reached before that of height. Measuring the patient’s height during the first and the follow up visits allows the clinician to determine by him/herself the growth velocity which is the most important parameter when evaluating the scoliosis risk progression.

The clinical examination needs to be completed by a hand radiograph when clinical data is considered not sufficient and any important decision must be taken.

Since a procedure must be synthetic and schematic, it may not deal with all possible questions arising during the clinical examination. The present paragraph is meant to clarify some aspects able to lead to different clinical decisions but which have not been included in the procedure. Some of the additional clinical elements are:

  • postural misalignment: when head and neck are off-balance with respect to the hips. The parameter can be measured and monitored over the time with a specific calliper enabling to calculate the percentage of translation;
  • reduction of physiological kyphosis, frequently present in more evolutive cases (in some peculiar cases addressed as flat back): its trend can be measured and monitored using the arcometer thus reducing the number of prescribed radiographies;
  • aesthetic appearance of the back: although being a subjective issue, the aesthetical aspect is linked to the kind of scoliotic curve which may become more visible and anaesthetic.

Some borderline cases require a careful evaluation since if one of the cut-off values is likely to determine important decisions, like prescribing radiographs or a brace, other aspects, not considered by the algorithm, can influence the decision making process too.

The accurate selection of patients can help reducing the amount of prescribed radiographs and the risk of losing those which may require some kind of treatment.
Radiographs should be asked by clinicians able to interpret them correctly and taken in well equipped centres.
The posterior-anterior projection is acquired having the patient standing and protecting gonads.
Whether the lateral projection can be of help is still a matter of discussion among clinicians. The lateral view is still recommended in many guidelines to complete the first visit, in any case of misalignment on the sagittal plane, such as the flat-back, or in case of pain. In all other cases, lateral projection probably does not add any useful information to the clinical evaluation.

Several brace types are available on the market and are named after the cities where they were developed (Milwaukee, Boston, Lyones) or after their characteristics (symmetrical, asymmetrical, thoracolumbar brace).

The type of brace is chosen by the clinician according to their level of expertise and considering curve type and location, patient’s physical and psychological aspects and the availability of an orthotist.

Considering the amount of elements which should be discussed, indications regarding the type of brace to be prescribed fall outside the purpose of this document.

The follow-up appointment can be fixed one year after the last visit if the amount of rotation is little and the growth velocity slow. A check-up would be necessary six months after the last visit if the rotation degree is close to the cut-off value and growth velocity is accelerating whereas a follow-up exam can be fixed after three or four months in case of progressive scoliosis.

In any case surface measurements help clinicians deciding if radiographs are necessary since, for example, if the degree of rotation is found to be stable during follow-up visits, spine alignment would probably have suffered no modifications.

The orthopaedic examination should take place in an experienced spine surgery centre if the patient suffers from a scoliosis with a Cobb angle greater than 40-45 degrees or has other clinical characteristics influencing spine alignment and deformity development.

The clinician can prescribe a brace to reduce scoliosis progression while waiting for the orthopaedic examination and if, indicated, until the time of surgery.

MEASUREMENTS TOOLS

How and which instruments to use in the evaluation

The clinical examination of the column, in addition to observation and some small maneuvers, can be enriched by a series of measurements with manual, non-invasive instruments. These instruments will never replace the X-rays simply because measuring the surface of the back does not coincide with measuring the column. However, they provide us with valuable information such as the identification of a range of normality and a threshold value, but above all they allow us to locate ,with precision, changes over time. The practice of using these instruments makes the repeatability of measurements excellent; the total absence of invasiveness allows to carry out all the necessary controls without limits

The inclinometer is a device with two important functions. On one hand the tool estimates the angle of trunk rotation during the Adam’s forward bending test while on the other hand helps measuring the Cobb angle on radiographs. The inclinometer, thus, can be used to evaluate spine curves on the frontal plane (scoliosis) and on the sagittal plane (kyphosis and lordosis).

The inclinometer is an almost rectangular-shaped device made of plexiglas with a goniometric scale. The tool has a small, rotating rod on its centre with a bubble on its shorter extremity. The longest side of the rod indicates the estimated values of rotation or inclination on the goniometric scale. If spinous processes are particularly protruding, the inclinometer can still be used placing its central recess over them.

During the forward bending test the patient has to reach the standard position with knees extended, arms hanging and trunk bent forward. The inclinometer is then placed on the back and the rod is moved until the bubble is centred. The clinician can read either immediately the angle of rotation or after the tool removal while fixing the rod between their fingers. The clinician is then able to identify the most rotated vertebrae simply repeating the measurements along the thoracic and lumbar segments.

The Cobb angle is found on radiographs by placing the inclinometer on the spine’s most tilted vertebra above the curve’s apex and then on the most tilted vertebra beneath the apex. The rod bubble has to be centred to determine the angle of inclination. The Cobb angle is found adding the two angles together.

The arcometer is a manual device used to measure spine curvatures on the sagittal plane, namely kyphosis and lordosis. The arcometer is made up of a ruled bar bearing three perpendicular arms. The first bar is fixed at one end, the arm in the middle can move on two axis while the last one can move on just one axis.

The leading principle is that just a single circumference passing through three identified points can be drawn.

The arcometer measures a chord and a rise which help calculating the Cobb angle and the curvature radius.

The Cobb angle identified during the clinical evaluation strictly correlates with the Cobb angle measured on radiographs. The curvature radius, on the other hand, can be of help especially when doing research.

The arcometer can be used to complete the clinical exam, as a screening test to refer the patient to a specialist or as part of the follow-up programme in patients affected by hyperkyphosis or flatback. The arcometer is also used to evaluate patients standing in their spontaneous and in their self-corrected posture since the comparison of the two measurements helps monitoring the disease progression and understanding the benefit gained from physiotherapy or from a spine orthose.

When measuring kyphosis or lordosis, the arcometer bars must be positioned at the superior and inferior apex of the curve. Their distance identifies the chord. The central bar, then, must be fixed to the midpoint of the chord with its lower extremity gently placed over the back. The value read on the ruled central bar is the rise.

The Cobb angle and the curvature radius can be calculated using the two-entry table provided together with the arcometer.

The torsiometer is a manual device used to measure the degree of trunk rotation while standing. The torsiometer is made up of two arch-shaped elements connected by a telescopic bar. The upper arch is parallel to the inferior one and has a degree scale printed on its surface.

The patient with a suspected scoliosis is evaluated standing “at attention”. The arch-shaped basis of the torsiometer is placed over the measurement reference point: the sacrum. The superior arch, then, is positioned over the vertebral segment which has to be analysed thus precisely showing the degree of trunk rotation.

The torsiometer can be used for different purposes:

  • the tool precisely identifies the degree of trunk rotation, one of the most sensitive clinical signs of scoliosis, while the patient stands at attention;
  • the tool allows to compare the degree of rotation while standing and during the forward bending movement. Such data, however, not always coincide and usually only approximately correlate with the vertebral torsion degree measured on radiographs;
  • the torsiometer allows detecting changes in the degree of vertebral rotation while performing a stretching exercise having the patient standing or in sitting position;
  • the clinician can use the torsiometer to evaluate the trunk range of motion and symmetry during an active rotation movement having the patients’ pelvis fixed thus preferably in sitting position.

The Delta-Leg is a manual instrument devised to measure limb length discrepancy with lthe patient supine. The device aims to improve the reproduciblity of the measurement compared to other non-invasive methods such as measurements with blocks or tapes.

The Delta-Leg is made up of a bar and two footboards, set perpendicular to it. One of the two boards is stationary and acts as a reference point while the second one can move along the main bar and is equipped with a pointer. The pointer indicates on the upper surface of the bar the positive or negative value of limb length discrepancy expressed in millimetres.

The measurement procedure

The patient is supine, head aligned with nose pointing at the zenith, trunk in line and parallel lower limbs with their patellae pointing at the zenith. The Delta-Leg bar must be positioned parallel to the legs. The stationary footboard has to be placed under the left foot with the clinician exerting a gentle pressure to ensure a broad sole contact, particularly to the heel. The mobile footboard, on the other hand, is placed under the right sole with the clinician exerting a gentle pressure on it.

The possible limb length discrepancy is immediately readable on the millimetre scale or just after the careful tool removal.

Note: in case of Achilles’ tendon retraction just a functional length discrepancy can be measured.

The calliper with long jaws is the same tool commonly used by orthosists to which has been added a sliding ring with a plumb line.

The plumb line has to be aligned with the intergluteal cleft to allow the evaluation of the hip/trunk/head shift with respect to the median line. The shift can be calculated with the two-entry table provided together with the tool.

The foot measuring device is a simple but precise tool which assesses the foot length. The latter is an important data since the peak of foot growth generally occurs two years prior to the peak height velocity and significant changes can involve the height-to-foot size ratio during the developmental phase.

If the ratio is higher than 16%, the patient is probably undergoing the foot growth spurt phase, typical of early adolescence. If the ratio is lower than 14.5%, the growth spurt may have already occurred by the visit time.

The ratio can be helpful during the first visit, when the clinician has little information concerning the patient’s developmental phase.

Spine curves on the sagittal plane can be described “measuring the arrows”, namely measuring the distance between the cervical or lumbar lordosis and a reference point, a pole or a wall, behind the patient.

The above-mentioned data can give indirect information about thoracic kyphosis and allow monitoring changes of spine alignment over time.

RADIOGRAPHS

When resorting to radiography

The accurate selection of patients can help reducing the amount of prescribed radiographs and the risk of losing those which may require some kind of treatment.

Radiographs should be asked by clinicians able to interpret them correctly and taken in well equipped centres.

The posterior-anterior projection is acquired having the patient standing and protecting gonads.

Whether the lateral projection can be of help is still a matter of discussion among clinicians. The lateral view is still recommended in many guidelines to complete the first visit, in any case of misalignment on the sagittal plane, such as the flat-back, or in case of pain. In all other cases, lateral projection probably does not add any useful information to the clinical evaluation.

The Cobb angle is calculated drawing firstly two parallel lines tangential the two must tilted vertebrae above and below the curve’s apex and, secondly, two perpendicular lines crossing the tangential ones .

The angle is measured at the intersection of the perpendiculars.

The inclinometer helps quickly identifying the most tilted vertebrae on radiographs.

On traditional radiographs, the Cobb angle can be drawn using ruler and pencil and measured with a goniometer. The inclinometer can ease the measurement simply placing the tool at the spine’s most tilted vertebra above and beneath the curve’s apex and adding their angle of inclination together.

If radiographs are seen on the computer, the Cobb angle is measured adding together the angles of inclination of the two most tilted vertebrae above and beneath the apex with respect to the horizontal line and using the tools available on the disk (see image).

If the vertebral edge cannot be clearly identified, the tangent to the pedicle is considered the reference point.

One of the typical elements of scoliosis is the spine twist. The term “vertebral rotation” indicates the torsion degree of the vertebrae at the curve’s apex which has generally the highest degree of rotation.

Several methods describe vertebral rotation. The most commonly used ones consider as reference point the pedicles’ asymmetry. The method of Raimondi is probably the most precise one but several others are still used such as the Nash & Moe and the Pedriolle ones.

The Risser sign describes a phase of skeletal maturity based on the observation of the iliac crest ossification stage. The ossification process starts from the most lateral portion of the iliac apophysis and continues until the whole iliac crest is completely fused.

Although the Risser sign is still widely used by clinicians, such a diagnostic tool does not provide any information about the initial stages of development. The ossification centre, indeed, is observed initially towards the end of the peak growth spurt.

The hand radiograph is asked to assess bone age and this ca be estimated with a six-month margin of error. The most commonly used reference standard is the atlas published by Gruelich and Pyle which analyses not only growth plates but also the form and dimension of phalangeal and carpal bones.

The hand radiograph is a precious tool when deciding whether or not starting any kind of treatment and whether or not asking a radiography of the spine in case reliable data about growth velocity curve should lack and in case of conflicting data about the developmental phase such as lower-than-normal growth velocity or menarche absence.

TEAM

Spine Path working group

  • DR FLAVIO D’OSUALDO

    Project Manager and written work

    Neurologist and Doctor of Physical Medicine and Rehabilitation, Past-Director of the Pediatric Rehabilitation Unit of the Rehab Hospital IMFR “Gervasutta”, Udine – Italy


  • DR ARIANNA MICHELUTTI

    Assistant Project Manager

    Doctor of Physical Medicine and Rehabilitation, La Nostra Famiglia, I.R.C.C.S. E. Medea, Pasian di Prato e S.Vito

  • DR ANNA PETRELLO

    Clinical Participant

    Doctor of Physical Medicine and Rehabilitation, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC) - Assistant Project Manager

  • DR ELISA BATTISTUZZI

    Clinical Participant

    Specialist doctor of Physical Medicine and Rehabilitation

  • DR FRANCESCA ZECCHINI

    Clinical Participant

    Doctor of Physical Medicine and Rehabilitation, Pediatric Rehabilitation Unit of the “Azienda Sanitaria Universitaria Friuli Centrale (ASU FC)”

  • DR SILVIA SPECOGNA

    Clinical Participant

    Doctor of Physical Medicine and Rehabilitation, Rehab Unit "Azienda Sanitaria Universitaria Friuli Centrale (ASU FC)”.

  • DR STEFANO SCHIERANO

    Clinical Participant

    Doctor of Physical Medicine and Rehabilitation, Pediatric Rehabilitation Unit of the “Azienda Sanitaria Universitaria Friuli Centrale (ASU FC)”