Scoliosis is diagnosed as one of three forms: idiopathic, which means the cause is unknown; congenital, which means the bones are asymmetrical at birth; or neuromuscular, which means the scoliosis is symptomatic of a systemic condition like muscular dystrophy, Friedreich’s ataxia, or cerebral palsy. In this case study, the patient suffers from neuromuscular scoliosis because he has cerebral palsy. Some of the signs that a person suffers from scoliosis include: •A spine that curves inward or downward too much •A leg that appears shorter than the other •A shoulder that appears lower than the other Ribs and pelvis rotate to the side •An asymmetrical chest shape Some of the problems associated with scoliosis include: •Numbness in the lower extremities •Fatigue •Back pain •Breathing problems Scoliosis is a chronic disease that gets worse over a period of time. Without diagnostic imaging, a curved spine that develops during early childhood can go unnoticed and untreated. This can affect the development of other muscles, ligaments, joints, and bones. The anatomy that you want to see in a proper scoliosis series includes the cervical, thoracic, lumbar, and sacral vertebrae, as well as the coccyx and pelvis.
There are seven cervical vertebrae (abbreviated C1-C7), twelve thoracic vertebrae (abbreviated T1-T12), five lumbar vertebrae (abbreviated L1-L5), five sacral vertebrae (abbreviated S1-S5) which are fused together, and four coccygeal vertebrae (commonly known as your tail) which are also fused together. Altogether, there are thirty-three vertebrae that make up the spinal column, with each vertebrae getting progressively greater in size as you go down the column. Scoliosis may occur in the cervical, thoracic, or lumbar regions. However, the most common site is in the thoracic region.
The anatomy of the pelvis that should be shown includes the ilium, ischium, pubic symphysis, and obturator foramen. Scoliosis may cause a rotation in the pelvis. As requested by the patient’s physician, AP and lateral radiographs were taken. For a proper scoliosis series, the views are done both in the erect and supine positions. However, because of the patient’s cerebral palsy he was not able to stand, so both views were done in the supine position only. For both views a 14” x 17” image receptor (IR) was used in a lengthwise position.
In most scoliosis series cases, a larger IR such as 14” x 35” will be used so as to fit all of the anatomy on one cassette. In this case, however, the patient’s size allowed the radiographer to use a smaller IR. The top margin of the IR should be placed at about the level of the nose and the bottom margin of the IR should be placed at about the level of the pubic symphysis for each view. In the AP view, the patient was laying on the table on his back, with his arms at his sides and his mid-sagittal plane centered to the midline of the IR.
The source-to image-distance (SID) was 40”, the central ray was perpendicular to the IR, and a tabletop technique of 70 kVp and 16 mAs was used. In the lateral view, the patient was turned onto his left side, placing his mid-sagittal plane parallel to the IR and his mid-coronal plane centered to the midline of the IR. There should be no rotation of the vertebral column, the vertebral bodies should be superimposed, and the ribs should be superimposed posteriorly. The SID was 40”, with the central ray perpendicular to the IR, and a tabletop technique of 77 kVp and 16 mAs was used.
Tight collimation was used to include only the area of interest, and a proper marker was placed for each image. Normally, the breathing instructions would be to hold your breath upon expiration, but since the patient was only three years old they could not follow those directions. For this exam a lead shield was not utilized, so that no useful anatomy would be cut. There are many radiographic exams that require the use of a contrast media, like barium sulfate or gastrographin, but a scoliosis series does not. The equipment used for this exam includes a Shimadzu YSF 200 R/F room, with a Linear MC-150 automatic collimator.
It uses a high frequency generator. A Fujifilm FCR XG-5000 computed radiography processor was used to develop the images. According to the physician’s diagnosis, the patient has a mid-thoracic dextroscoliosis between the T3/T4 and T8/T9 vertebrae that measures 18 degrees. Dextroscoliosis means that the convexity, or the curvature of the spine, is on the right side. He also has a lumbar levoscoliosis between the T9/T10 and L3/L4 vertebrae that measures 48 degrees, which is an extreme curvature. Levoscoliosis means that the curvature of the spine is on the left side.
The patient’s chances of recovery from scoliosis vary upon a few factors, the most of which depends upon the progression of his cerebral palsy. Treatment for scoliosis can be done using back braces or with the help of surgery. Back braces can be useful for curves between 20-40 degrees, however bracing doesn’t cure the scoliosis, it just keeps it from getting much worse. They are usually recommended for children that have bone growth remaining. Surgery is done for patients with curves over 40-50 degrees, and with a high likelihood of progression of the disease. In this case study, surgery might be a good option for the patient.
It is usually impossible to completely straighten the spine, but in most cases very good corrections are achieved. As shown, radiography plays a great role in helping to diagnose scoliosis and show its progression. Doctors recommend that x-rays should be taken at least every 6 months until the curve stops increasing. Bibliography Eisenberg, Ronald L. (2007). Comprehensive Radiographic Pathology. St. Louis: Mosby Elsevier Frank, Eugene (2007). Radiographic Positioning & Procedures, Edition 11 Volume One. Mosby Elsevier Kouwenhoven, J & Castelein, R (2008). The Pathogenesis of Adolescent Idiopathic Scoliosis, Volume 33. The Martindale Press
