LOIS Clinical examination

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Clinical assessment

Special Considerations for the Adolescent Patient:

• The examination requires delicacy in execution due to the adolescent's critical developmental period and focus on body image.

• Establish comfort and trust: Sit down, take time, and minimise traffic in the examination room.

• Privacy: Close the door and encourage the child to wear a swimsuit.

• Involve the patient: Talk to the patient directly before consulting parents.

• Language: Speak clearly, using sensitive language (avoid terms like "deformity").

• Honesty: Be honest and open about the condition.

• Non-threatening approach: Examine remote body parts, examine younger children in a parent's lap, and observe movement without direct touch (e.g., walking on heels/toes, deep knee bend, "duck walk").

• Avoid objectification: Spend ample time with the child and parents, not just on imaging studies, as the diagnosis is emotionally charged for a child.

Observations:

• Age and Gender:
• Note the patient's age (as a measure of maturity and progression risk) and gender (girls have a higher likelihood of progression).
• Children in the first decade have a higher risk of neural lesions.

• Gait:
• Observe the child's walk for signs of neural disease (e.g., ataxia) or antalgic gait, and evaluate skeletal balance.

• Pain:
• Ask about significant pain.
• While pain incidence in idiopathic scoliosis is similar to the general population,
• Look for other primary aetiology or rapid progression for the following:
• Pain associated with other symptoms
• Pain that awakens a child from sleep
• Constant pain

• Skin Inspection:
• Inspect for stigmata of dysraphism,
• such as abnormal hair, angioma, lipoma, and dimples.
• While some midline lumbosacral dimples are normal, others may indicate neural anomaly, often requiring MRI screening.
• Look for stigmata of non-idiopathic spinal disease, such as café au lait spots or axillary freckling, which suggest neurofibromatosis.

Upright Back Examination:

• Spinal Balance:
• Plumb Line Test:
• Drop a plumb line from the inion or vertebra prominens.
• A deviation of more than 2 cm from the natal cleft is atypical for idiopathic scoliosis and may suggest underlying neural disease.

• Back Midpoint:
• Identify the back midpoint at the maximum width of the thorax and determine its deviation from the natal cleft.
• This measures truncal decompensation and is a risk factor for progression, seen more frequently in single curves.

• Palpation of Spinous Processes:
• Palpate from the vertebra prominens to the sacrum to gauge curve magnitude and rotation.
• Rotation is always towards the concavity of the curve.
• Absence of spinous processes may indicate spina bifida occulta.

• Secondary signs of scoliosis producing truncal distortion
• Look for secondary signs of scoliosis caused by spinal rotation in the transverse/axial plane. These include:
• Rib or flank prominence (occurs on the convexity of the curve).
• a sign of the spinal rotation in the transverse or axial plane that accompanies curvature in the coronal plane, and it occurs on the convexity of the curve
• Flank asymmetry
• may be the only sign in an overweight child, in whom chest asymmetry is more easily obscured.

• Shoulder elevation.
• Flank flattening or indentation.
• Scapular rotation or elevation.
• Iliac crest prominence or elevation.
• Iliac crest asymmetry may suggest lower limb length discrepancy, which should be neutralised with blocks for accurate spinal curvature assessment.

Upright Side Evaluation (Sagittal Contour):

• Scoliosis is a three-dimensional deformity, altering sagittal contour. Spinal rotation can lead to a loss of thoracic kyphosis and lumbar lordosis, effectively flattening the spine.

• Atypical Sagittal Contour:
• Increased thoracic kyphosis is a very sensitive indicator of underlying neural disease.
 

• Sagittal Imbalance:
• This is the greatest predictor of pain from spinal deformity
• necessitates examination of lower limbs for contracture or primary deformity.
• For example:
• Hip flexion contracture may tip a patient forward.
• Lower limbs for length discrepancy

Adams Forward Bend Test:

• Technique
• The patient bends forward with the spine horizontal, neck relaxed, knees extended, feet together, upper limbs dependent, and palms opposed.
• Can be assessed from the back or front.
• Assess the following
• Truncal Rotation:
• Assess prominence of the chest and flank.
• This prominence can be quantified using an inclinometer (scoliometer) centred over the apical spinous process.
• Seven degrees of trunk rotation corresponds with approximately 20 degrees of coronal deviation (Cobb angle), which is a common referral threshold.
• Other Etiologies:
• Limitation or asymmetry of forward bending may uncover scoliosis arising from painful conditions (e.g., osteoid osteoma, spondylolisthesis) or global neural diseases (e.g., hamstring contracture).
• Sagittal Contour Exaggeration:
• Thoracic kyphosis (as in Scheuermann disease) may be amplified, sometimes leading to misdiagnosis of scoliosis when the primary issue is hyperkyphosis.

Neural Examination:

• To rule out a lesion of the neuraxis, which can be the primary manifestation of spinal deformity.

• Evaluate:
• Sensory and motor function in the lower limbs,
• Reflexes (Abdominal reflex, patellar ligament, Achilles tendon)
• Consistent contraction of abdominal muscles on one side and consistent absence on the other is abnormal.
• Look for upper motor neuron signs (e.g., ataxia, clonus).

• Further Evaluation: An abnormal neural finding warrants MRI from the occiput to the sacrum to look for four principal lesions:
• Chiari malformation (Type I: cerebellar tonsil displacement caudal to foramen magnum).
• Syrinx (fluid in the spinal cord distinct from central canal expansion).
• Diastematomyelia (splitting of the spinal cord).
• Tethered cord (thickened filum terminale restricting spinal cord migration during growth).

Maturity Determination:

• Maturity is one of the two principal determinants of progression (the other being curve magnitude).

• Elements assessed during physical examination:
• Peak height velocity: Occurs about 6 months before menarche in girls and is the period of greatest progression risk. It is identified retrospectively.
• Menarche:
• Marks the end of peak height velocity and the beginning of growth slowing, occurring after the highest risk period. It only applies to girls and can vary.
• Secondary sexual characteristics: Tanner staging is considered the simplest, fastest, least expensive, and least morbid method to assess maturity in the office. Peak height velocity roughly corresponds with Tanner stage 3.

• See skeletal maturity
• It should be noted that in addition to menarche, the iliac apophysis is absent (Risser stage 0) and the triradiate cartilage is open at the conclusion of the peak height velocity phase, making these poor differentiators during the most critical period for progression (Fig. 9).
• The conclusion of peak height velocity corresponds roughly with Tanner stage 3.

Cosmesis:

• Appearance is the greatest concern for adolescents with scoliosis and should be addressed by the surgeon as it is central to outcome. Key components include:
• Breast shape:
• Surgical correction may not significantly improve breast asymmetry, and plastic surgeon consultation might be considered.
• Rib prominence:
• This is often noticeable through clothing.
• Thoracoplasty can be discussed if important to the patient.
• Shoulder height:
• Surgeons must aim to level or reduce shoulder height differences during surgery, as there is no secondary fix if it remains a concern.
• Surgical scar:
• The dissatisfaction with anterior oblique thoracolumbar scars is greater compared to posterior midline linear scars among adolescents.

Examining rest of the patient:

• Beyond the spine and trunk, the surgeon must look for stigmata of other diseases that would disqualify the diagnosis of idiopathic scoliosis. Examples include Marfan syndrome (tall stature, dolichostenomelia, arachnodactyly, high-arched palate), Sprengel deformity (scapular elevation with restricted shoulder motion), and cavus foot (may signal a spinal cord lesion).