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scoliosisseminarfinal-190115143952 (1).pptx

Scoliosis is a lateral curvature of the spine with associated vertebral rotation. It is classified based on etiology (idiopathic, congenital, neuromuscular), age of onset (infantile, juvenile, adolescent), and structural severity. Diagnosis involves history, exam assessing curve magnitude via scoliometer and x-ray, and determining flexibility. Treatment depends on curve progression risk and may include bracing or surgery to prevent pulmonary and pain complications from severe deformity.

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Dr. Uzair Rashid
DEFINITION • “Scoliosis” - Greek word meaning “crooked.” • Scoliosis is defined as lateral deviation of the normal vertical line of the spine, which when measured on a radiograph, is greater than 10 degrees ,with associated rotation of vertebrae • Patients with curves less than 10 degrees are considered to have spinal asymmetry 2:39PM
• The lateral curvature of the spine is associated with rotation of the vertebrae within the curve- • a three-dimensional deformity occurs in three planes: (1) lateral intervertebral tilting in the frontal plane (2)a rotatory component in the axial plane (3) intervertebral extension in the sagittal plane leading to lordosis of the scoliotic segment
• The common right (dextro) thoracic curve, (measuring 10°) - considered physiologic - to accommodate the size and position of the heart, lung, and aorta or to be related to handedness. • 7 times more prevalent in females • 80% of scoliosis origin unknown
Lateral displacement Angular displacement
Classification  Structural ( radiographically Cobb angle of 25° or more on ipsilateral side-bending radiographic views)  Non-structural - compensatory and postural
Based on aetiology : • Idiopathic • Congenital • Neuromuscular • Syndromic AGE-BASED: (idiopathic)  infantile(birth and 3 years)  juvenile (3 and 10 years ofage)  adolescent (10- skeletal maturity) MC
NON STRUCTURAL • A reversible lateral curve of the spine that tends to be positional or dynamic in nature. • No structural or rotational changes in the alignment of the vertebrae. • Disappears when the patient is supine or prone or sitting . 2:39PM
Correction of the lateral curve is possible by: -Forward or side bending -Positional changes and alignment of the pelvis or spine. -Muscle contraction -By correction of a leg-length discrepancy
Etiology of Nonstructural scoliosis- • Leg length discrepancy: (structural or functional) Measurable difference because of a dislocated hip, asymmetric leg or foot postures. • Habitual asymmetric posture: Sitting with weight shifted onto one hip or standing with weight primarily supported on one leg • Muscle guarding or spasm from a painful stimuli in the back or neck
CONGENITAL SCOLIOSIS • Congenital scoliosis is a progressive three- dimensional deformity of the spine caused by congenital anomalies of the vertebrae that result in an imbalance of the longitudinal growth of the spine. • the familial incidence = 1% to 5% • more common in girls (3 : 2)
• Anomalies occur in 30% to 60% • MC -the spinal cord and the genitourinary tract. • Intraspinal anomalies include - tethered cord, diastematomyelia, and syringomyelia. • The most common genitourinary defects are renal agenesis, ectopic kidney, duplication, and reflux. • VACTERL association : Vertebral defects (V), Anal atresia (A), Cardiac defect (C), Tracheoesophageal fistula (TE), Radial limb reduction, and Renal defects (R) and Limb defect (L) • in Klippel-Feil syndrome, Marfan syndrome, Ehlers- Danlos syndrome, Charcot-Marie-Tooth disease.
NEUROMUSCULAR SCOLIOSIS • The second most common form of scoliosis and is associated with disorders of the nerve or muscular systems, such as: a)Neuropathic - • 1)Lower motor neuron(e,g.poliomyelitis) •2)Upper motor neuron(e,g. cerebral palsy) b)Myopathic - 1)Progressive(e,g. muscular dystrophy) 2)Static(e,g. Amyotonia congenita) 3)others(e,g.Friedreich’s ataxia, unilateral amelia)
• These cause muscles to become weak, spastic or paralyzed — and unable to support the spine, resulting in spinal curvatures. • Treatment will depend on child's age and underlying condition, as well as the type and severity of the spinal curve.
IDIOPATHIC SCOLIOSIS • Idiopathic scoliosis is the most common type of scoliosis. • defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine in the absence of any known cause • Idiopathic scoliosis is divided into three categories based on chronologic age: -infantile (birth to 2 years+ 11 months) -juvenile(3 years to 9 years+11 months), -adolescent (10 years to 17 years+11 months) 2:39PM
INFANTILE IDIOPATHIC SCOLIOSIS • Common in Europe • Male predominance • Left thoracic curve pattern is most common • Two types have been identified: a resolving type (85%) and a progressive type (15%)
• curves that can progress can be obtained from the rib-vertebral angle difference (RVAD) and “phase of the rib head.” • If the head and neck of the convex rib of the vertebral body at the apex of the curve does not overlap the vertebral body, it is termed phase I • if it does overlap, it is termed phase II. • Curves with RVAD greater than 20 degrees or phase II angles are very likely to progress 2:39PM
JUVENILE SCOLIOSIS • 12%–16% of all patients with idiopathic scoliosis • Increasing female predominance • Most common curve patterns are right thoracic • Approximately 70% of curves progress
ADOLESCENT SCOLIOSIS • most common type of scoliosis in children • A female predominance • Thoracic curve patterns are generally convex to the right • Idiopathic scoliosis in adolescence is not typically associated with severe pain
CLINICAL FEATURES • Deformity is usually the presenting symptom • Pain • Rib hump or abnormal para spinal muscular prominence (indicates spinal rotation) (Rib hump leads to asymmetry of trunk called angle trunk rotation (ATR) )
• Raised shoulders(thoracic curves-convex side) (Lumbar curves – concave side) • Scapula – rotated outwards and forwards with elevation on convex side • Increased flank creases – concave side • Higher ASIS PSIS – concave side 2:39PM
Physiological Effects of Scoliosis • Mid-back pain • lower back pain, • neck pain, headaches, • premature disc and joint degeneration • Decreased pulmonary function
MANAGEMENT
Patient history • Age at onset • Evidence of maturation • Back pain • complete neurological history • Family history • Self-perception
Physical examination • Height measurement • Gait check • Foot shape • Skin inspection • Assessment of pubertal development • Neurological examination ( including motor, sensory and reflex tests ) • Symmetry of shoulders and iliac crest 2:39PM
Assessment of scoliosis •the four basic spinal parameters evaluated in scoliosis are  curvature  rotation  flexibility  skeletal maturation
SCOLIOMETRY The Scoliometer is placed on the back and measures the apex (the highestpoint) of the upper back curve.
• Plumb line - On posterior aspect, line drawn from occiput should normally align with gluteal `cleft
ADAM’S FORWARD BEND TEST
•Simple curve-Single spinal deviation • Compound curve- Displacements in Right & Left direction •Primary curve- Curve that develops first • Secondary or Compensatory curve- Develops as a balancing response to the primary curve
• Non structural curve- Curve is flexible and corrects by bending towards convex side
STRUCTURAL SCOLIOSIS • Non correctable deformity of affected spinal segment. • Vertebral rotation is an essential component • Spinous process swing round towards the concavity of the curve. • Transverse processes on the convexity rotates posteriorly.
• To determine the severity of the curve • X-ray Antero Posterior, Lateral & Oblique view of spine • Right & left bending view – determine the degree of flexibility of spine & to see how much curve can be passively corrected
THORACIC curve – STRUCTURAL LUMBAR curve – COMPENSATORY 2:39PM
•The end vertebrae (E) -are most tilted •Apical vertebra(A)- is the central vertebra within a curve. It is typically the least tilted, most rotated, and most horizontally displaced vertebra within a curve •A neutral vertebra (N) - one that is not rotated •a stable vertebra (S)- is one that is bisected or nearly bisected by the CSVL (dotted line)
CURVATURE MEASUREMENT • COBB- LIPPMANN : • most accepted • AP radiograph entire spine • a line is drawn along the superior borderof the cephalad end vertebra and inferior surface of the caudad end vertebra • Perpendicular lines are erected from each endplate line, and the vertical (not horizontal) angle formed by their intersection is measured 2:39PM
Double curve • One vertebra is upper end vertebra for lower curve and lower end vertebra for upper curve (transitional vertebra). • Only one line drawn on this vertebra.
King-Moe classification • Published in 1983 • thoracic curve patterns • five curve types as a guide to surgical treatment •The King classification does not address lumbar curves, thoracolumbar curves, or triple major curves.
•Type 1: S-shaped curve in which both the thoracic and lumbar curves cross the midline. Both curves are structural, and the lumbar curve may be larger or less flexible than the thoracic curve • Type 2: S-shaped curve in which the thoracic curve is larger or less flexible than the lumbar curve (also called a “false” double major curve) • Type 3: Single thoracic curve without a structural lumbar curve •Type 4: Long thoracic curve in which L5 is centered over the sacrum and L4 is tilted into the thoracic curve • Type 5: Double thoracic curve with T1 tilted into the convexity of the
• two-dimensional classification system, published in 2001 • included the sagittal plane as well • PT,MT,TL/L curves are measured using the Cobb technique. • The larger of the latter two is considered the major curve. • Lesser curves are termed minor and are considered structural : - if they remain at least 25 on side-bending films or -Hyperkyphosis in the PT region (T2–T5>20) or TL(T10– L2>20) ,regardless of their sidebending measurement.
• PT curves are always minor • 42 curve patterns • The type 1 (single thoracic) curve is the most common The general principle : • major curve and structural minor curves should be fused • nonstructural minor curves may be allowed to correct spontaneously following fusion of the structural curves. 2:39PM
LIPPMAN - COBB’S classification GROUP ANGLE OF CURVATURE I <20 II 21-30 III 31-50 IV 51-75 V 75-100 VI 101-125 VII >125
Cobbs pitfall • diurnal variation of 5° • difficult to position the patient • intraobserver variation by 5°–10° in Cobb angle
•Center of each end vertebra and the apical segment are joined, and their intersecting acute angle is measured. Risser -Ferguson systems
SCOLIOTIC INDEX • Each vertebra (a–g) is considered an integral part of the curve. • A vertical spinal line (xy) is first drawn whose endpoints are the centres of the upper and lower end- vertebrae of the curve. • Lines are then drawn from the centre of each vertebral body perpendicular to the vertical spinal line (aa', bb', … gg').
• Represent the linear deviation of each vertebra • Sum of vertebral body lines, divided by the length of the vertical line (xy) gives the scoliotic index
D E G R E EO F R O T A T I O N • Rotation – reflects the degree of structural change & resistance to correction of the scoliotic curve 2 methods are used- • Moe pedicle method • Cobb spinous-process method. 2:39PM
NASH AND MOE
COBB SPINOUS-PROCESS METHOD • Migration towards the convexity of the curve marks the degree of rotation.
DETERMINING MATURATION • Secondary sex characteristics • Excursion of iliac apophysis (Risser's staging) • Ossification of the vertebral ring apophysis. • Triradiate cartilage • Bone age
RISSER’S STAGING •first appears laterally near the ASIS and progresses medially toward completion at the PSIS (capping) •Boys -16yrs; Girls 14yrs •grade 4 in F and grade 5 in M usually signals the end of curve progression
Vertebral Ring Epiphyses • closely parallels the maturation of spinal growth. • most accurate indicator of completed spinal growth • strong inhibiting factor to future scoliotic progression.
TRIRADIATE CARTILAGE • Y- shaped epiphyseal plate that occurs at the junction where the ischium, ilium and pubis meet in the skeletally immature skeleton • Closure or fusion - 15 - 16 years in males 13 - 14 years in females • beginning at the acetabulum and finishing at the greater sciatic notch between ilium and ischium.
Assessment of Vertebral Alignment and Balance • The plumb line: vertical line drawn downward from the center of the C7 vertebral body, parallel to the lateral edges of the radiograph • CSVL : vertical line that is drawn perpendicular to an imaginary tangential line drawn across the top of the iliac crests on radiographs. It bisects the sacrum.
CORONAL BALANCE •evaluated by measuring the distance between the CSVL and the plumb line •greater than 2 cm is abnormal SAGITTAL BALANCE • evaluated by measuring the distance between the posterosuperior aspect of the S1 vertebral body and the plumb line
The Probability of Progression • curve progression parallels spinal growth. • progresses only during growth • ceases when skeletal maturity is reached (final curvature is not severe) • > 50 degree -more Morbidity mortality (cardiopulmonary complications) 2:39PM
• less than 30°: tends not to progress • After the cessation of spinal growth, only curves with a Cobb angle greater than 30° - monitored for progression • Lumbar and thoracolumbar curves are more likely to progress than thoracic curves because they lack the inherent stability provided by the rib cage.
• Congenital scoliosis progresses in 75% of cases • Idiopathic Infantile rarely progress • Idiopathic Juvenile progress 75-80% • Idiopathic Adolescent progress only 5% • The factors that have the greatest effect on scoliosis are spinal growth velocity and magnitude of the curve at initial presentation
TREATMENT Dr.Lewis Sayre
Infantile idiopathic scoliosis • Resolving curves: -observed -serial physical examinations and radiographic monitoring. -Sleeping in the prone position- recommended • Progressive curves – treated with serial casting followed by orthotic treatment
Treatment options forprogressive curves • Serial casting + bracing+ later fusion • Preoperative traction + later fusion • Growing rod or vertical expandable prosthetic titanium rib( VEPTR) instrumentation without fusion
• Best results if casting started < 20 months of age and<60 degree curves • Cast change every 2-4 months • Once corrected to < 10degrees -use custom moulded brace
Operative treatment • Indicated if curve is severe or increases despite use of an orthosis/casting • Principle of surgery- surgery should not only stop progression of the curve but also allow continued growth and development of the thorax and lungs • Fusionless instrumentation techniques are preferred(VEPTR)
• Posterior spinal instrumentation and fusion are not recommended due to: – restriction of thoracic cage and lung development – the risk of crankshaft phenomenon (persistent anterior spinal growth in the presence of a posterior fusion, leading to recurrent and increasing spinal deformity). • Growing rods may be used to control curve progression and still allow for growth of the spine . • Requires surgery every 6 months to lengthen the rods • The use of magnetically controlled growing rods , such as the MAGEC
Magnetically controlled growing rod •magnetic technology with adjustable growing rods and an external remote controller • spinal bracing and distraction system •avoids a return to surgery every 6 months
CRANKSHAFT PHENOMENON • With a solid posterior fusion, continued anterior growth of the vertebral bodies causes the vertebral body and discs to bulge laterally toward the convexity and to pivot on the posterior fusion • causing loss of correction, increase in vertebral rotation, and recurrence of the rib hump • Combined fusion necessary- to prevent crankshaft phenomenon
Treatment of juvenile idiopathic scoliosis • Orthotic treatment is initiated for curves in the 25° to 50° range. • Surgical treatment is considered when curve magnitude exceeds 50° • convex disc stapling - an option for fusionless correction of scoliosis
Surgical options • principle of surgery – posterior instrumentation that is sequencially lengthened to allow longitudinal growth while still attempting to control progressive spinal deformity. • Growing rod-surgery is required every 6 months to lengthen the construct • Dual growing rod- effective in controlling severe spinal deformities and allowing spinal growth
Guided growth and physeal stapling – •Principle of surgery- interertebral stapling is used to produce a tethering effect on the convex side of the spine. •This will allow for continued growth on the concave side of the spine deformity and gradual correction of the deformity with growth
Adolescent idiopathic scoliosis Nonoperative treatment- 1.observation- young patient with mild curve <20 2.orthotic treatment- • progression of curve beyond 25 • Curve of 30-40 in skeletally immature SRS optimal inclusion criteria for bracing: • Age 10yrs or older • Risser grade 0-2 • Primary curve angle 25-40 • No prior treatment 3.Underarm cast
Orthosis (Bracing) • to prevent curve progression • Successful brace treatment is the initial correction achieved by 50% or more upon initiation of bracing • braces are applied when a curve is progressing and is between 20 deg and 40 deg. • rarely does a brace work after a curve is 40 deg or greater
Contraindication s of brace treatment : • Skeletally mature patients • Curves greater than 40° • Thoracic lordosis (bracing potentiates cardiopulmonary restriction) • Patients unable to cope emotionally with treatment
Type of Braces (Milwauke e Used les s •CTLSO brace). commonl y due to its cosmetic appearance. However, for curves with an apex above T8, it remains most efficacious •TLSO (e.g. Boston brace). These lower- profile orthoses are better accepted by patients and are indicated for curves with an apex at T8 or below
• Bending brace (e.g. Charleston brace). - holds the patient is an acutely bent position in a direction opposite to the curve apex. It is worn only during sleep. • Flexible brace (e.g. SpineCor brace)
HALO-TRACTION DEVICE: • A spinal skeletal traction and fixation device • attached to the skull and is connected to a plaster body cast by an adjustable steel frame. • especially valuable in scoliosis when cardiopulmonary insufficiency contraindicates the use of corrective cast. • used with distal traction through pins inserted in the distal femurs or proximal tibias , permitting the use of respiratory aids and surgery while in traction.
Prognosi s- • Factors : – Curve magnitude : more angulation & rotation, progress more (>20) – Age : younger, progress more (<12yo) – Risser’s score : score 0-1, progress more – Curve length : shorter curves, progress more – Location : higher curves, progress more – Flexibility : stiffer curves, progress more
Operative /Surgery Objective : • obtain a solid fusion and to have the top and the bottom of the fusion balanced within the stable zone. Indications for surgery : • <30 failed conservative treatment • 30 - 45, with progression • >30 with cosmetically unaccepted in skeletal maturity • Increasing curve in growing child • asymmetry of trunk in adolescent • Pain uncontrolled by nonoperative treatment • Thoracic lordosis • Significant cosmetic deformity
Goals : • Halting progression • Achieve correction • Achieve spinal balance Objectives : • Reduce rotational deformity & lateral deviation • Athrodese the primary curve
• pulmonary function tests preoperatively on all patients. • cardiopulmonary compromise present - posterior fusion is preferred over an anterior approach to avoid pulmonary insult of a thoracotomy • clinical appearance of shoulder height and symmetry is important in the selection of fusion levels.
Types : • Posterior approach • Anterior approach • Combined posterior & anterior approach • Video-assisted Thoracoscopic Surgery (VATS)
Posterior surgeries: -Posterior spinal instrumentation- • pedicle hook implantation • sublaminar wires and cables • Pedicle fixation- lumbar pedicle screw -thoracic pedicle screw -Facet fusion- Moe/Hall technique
Harrington rod Instrumentation
Luque trolley: • uses wires to facilitate spine growth • the wires slide along contoured rods. Shilla procedure: • spinal fusion at the most severe portion of the scoliotic curve; termed the apex. • anchor points at the top and bottom of the curve. • The screws at the ends of the spine are specially designed to allow movement and growth along the rod
SHILLA LUQUE