Common Pediatric MSK Concerns


Scoliosis, or curvature of the spine, is an important, and frequently insidious, deformity that may appear during childhood. While many etiologies may be responsible for scoliosis (congenital bony abnormalities, neuromuscular weakness, intraspinal pathologies), the most frequent type of scoliosis is termed "idiopathic" reflecting a lack of known etiology. Similarly, while all ages can be affected from infancy on, most patients develop scoliosis during their adolescent growth spurt. This module will focus on adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis is more common in girls. The difference is striking in patients with large curves (>30o) where the female:male ratio is 10:1. The spinal deformity is frequently noted by a parent as the patient may be unaware of it. Scoliosis has a tendency to be familial, although the size of the curve in the parent does not predict that of the child and the inheritance is sporadic.

Physical examination is the place to start. The patient should be appropriately dressed (usually in a gown that opens at the back). Observe the spine from the back and from the side with the patient standing unsupported. Make sure that both feet are flat on the floor and that the knees are held symmetrically in extension. Look for asymmetry at the level of the shoulder, scapula, waist and pelvis. From the side, observe for abnormal contours in the thoracic or lumbar spine. Ask the patient to bend forward at the waist while keeping the knees extended. Look for asymmetry from the back ("rib hump" or "lumbar prominence") indicating scoliosis or the side ("thoracic hump") indicating fixed kyphosis. A postural deformity (such as "postural roundback") will resolve with forward flexion with will be evident when observing from the side. In addition to inspection of the back, a full neurological examination is required. Pay close attention to muscle power and reflexes. If a patient is acutely in pain, scoliosis may be positional and transient due to muscle spasm

Scoliosis is significant for the following reasons:

  1. Large curves (100o or more) will cause restriction of cardiopulmonary function leading to severe consequences
  2. Trunkal asymetry may cause significant cosmetic concerns
  3. Patients with lumbar curves >35o have an increased incidence of lower back pain in adulthood
  4. Scoliosis may be secondary to an underlying spinal problem (tumour, tethering) or bony disorder (vertebral osteoid osteoma). These patients (unlike patients with "idiopathic" scoliosis) present with pain as a predominant complaint.