SHEUERMANN+DISEASE.pptx

SHEUERMANN+DISEASE.pptx

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  SHEUERMANN DISEASE Dr. sajilkrishna k
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  • Structural kyphosisof thoracic or thoracolumbar spine • Unknown etiology • Incidence: 0.4-10% of adolescent ( 10- 14 years of age) • Onset: during prepubertal growth spurt, apparent at around 10-12 years of age • Sex: M>/=F
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  Definition • Normal kyphosisof thoracic spine(scoliosis research society) – 20-45 degree( T1- T12) • Angulation >45 degree – hyperkyphosis • Normal lumbar lordosis :- 50-70 degree ( L1-S1) • Normal thoraco lumbar junction : 0-10 degree • Sagittal gravity line passes through spinous process of T1, T 12 and sacral promontory.
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  • Characterised by vertebralwedging thoracic kyphosis of >40 degree >5 degree anterior wedging of 3 consecutive adjacent vertebral bodied at apex of kyphosis Schmorl’s nodes Irregualr end plate Narrowing of vertebral disc space Increased vertebral AP diameter at apex
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  History • Initially knownas “Apprentice or muscular kyphosis” • Holger Werfel Scheuermann (1921) described as “ Kyphosis dorsalis juvenilis”
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  Aetiopathogeneis ( theories) •Scheuermann vertebral epiphyseal disturbance theory • Schorml et al – vertebral wedging caused by herniation of disc material into vertebral body • Ferguson et al – anterior vascular groove in v. body- structural weakness- wedging- kyphosis • Bradford et al – secondary to vertebral osteoporosis during juvenile period • Ippolito and ponseti et al :- biomechanical abnormality of collegen and matrix od v. body end plate cartilage
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  • Frank Damborget al : genetic theory • Mechanical factors: supported by bracing therapy as treatment, commonly seen in heavy weight lifting or manual labour
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  Anatomic and histologicalchanges • Gross: * thickened ALL * narrowed vertebral disks * wedging of vertebral bodies
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  • Histology * abnormalityof cartilaginous endplate include disorganized endochondral ossification • Collagen * proteoglycan ratio in endplate matrix is low * results in alteration in ossification of endplate causing altered vertical growth
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  Types 1. Typical scheuermanndisease 2. Atypical scheuermann disease
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  Typical scheurmann disease •Most common • Usually involve thoracic spine • Involve >/= 3 consecutive vertebrae each wedged >/= 5 degree • Producing structural kyphosis
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  Atypical scheuermann disease •Usually located in the thoracolumbar junction or lumbar spine • Vertebral end plate changes, disc space narrowing, anterior schmorl nodes • Doesnot necessarily have 3 consecutively wedged vertebrae of 5 degree
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  Clinical features • PAIN •DEFORMITY and its progression • NEUROLOGIC COMPROMISE • CARDIOPULMONARY COMPROMISE • COSMETIC and POSTURAL PROBLEM
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  Pain • MC complaintsin adult • Located just distal to the apex of the deformity in the paraspinal location • Commonly activity related pain • Relieved immediately with rest and usually are not activity limiting • Hyperlordosis distal to thoracic deformity and degenerative disc and facet arthropathy predispose low back apin.
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  • Adolescent presentwith progressive low back pain and may interfere with activities of daily living, pain radiating to buttocks and lower extremities, and may awaken from sleep
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  Deformity • Progressive deformitycause patient to seek tx
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  Neurologic compromise • Cordcompression secondary to scheuermann disease is rare, may need sx. • Variable onset • Ranging from acute onset of unilateral radiculopathy to insidious onset of spastic paraplegia • Cause is that spinal cord is draped over apex of deformity • Can also due to extradural cysts, acute thoracic disk herniations( 4- 7%)
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  Cardiopulmonary complaints • Extremelyrare on initial presentation • Restrictive pulmonary disease in kyphosis > 100 degree, with apex in upper thoracic region
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  Physical examination • Erectpatient demonstrate increased thoracic kyphosis with sloping shoulders • Forward posturing of head and neck ( due to increased cervical lordosis) • increased lumbar lordosis with weakened abdominal muscles causing mildly protuberant abdomen • Adam’s forward bend test :-slight truncal asymmetry associated with mild scoliosis,, side view gives “ A” frame deformity due to abrupt angulation
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  • Deformity isnot easily corrected with postural changes or passive manipulation • Lumbar lordosis is usually reversible, flexible and corrects with forward bending. But cervical lordosis may become fixed. • Neurological exam may normal • Tight or contracted hamstring and pectoral muscles • Arms and legs appear relatively long compared to trunk
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  Radiologic evaluation
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  1. Standing PAview • May show mild scoliosis that rarely > 25 degree and show minimal vertebral rotation • Allows assessment of skeletal maturity (RISSER SIGN- BY DEGREE OF OSSIFICATION OF ILIAC APOPHYSIS)
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  2. Lateral 36inch (90cm) spine erect • with hips and knee extended, arms resting at shoulder height on a crossbar infront. • Reveals thoracic kyphosis over 40 degree ( Cobb technique) • To r/o associated conditions • Radiographic criteria by Sorenson 1) >5o of anterior wedging of 3 consecutive vertebral bodies at apex 2) irregular vertebral apophyseal lines with flattening and wedging 3) narrowing of intervertebral spaces and variable presence of schmorl’s nodes
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  Hyperextension lateral imageof thoracic spine • To assess flexibility of kyphosis
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  Lumbar scheuermann’s disease •Lateral view show decreased lumbar lordosis and possible kyphotic deformity at thoraco lumbar junction • Lumbar vertebrae is scalloped with lucent defects at anterosuperior corners • Schmorl nodes and endplate irregularity
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  MRI • For atypicalor rapidly progressive kyphosis or any neurological signs or symptoms • Mainly for preoperative evaluation
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  Natural history • Untreatedkyphosis may progress if deformity is severe • Adults with mild residual kyphosis will have little, if any are not likely to seek treatment • Pain in adults due to degenerative spondylosis often sequel of untreated scheuermann disease, usually resistant to non operative treatment and not usually seen kyphosis<60o • Pulmonary compromise if curve >100o • Type II scheuermann almost never require sx
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  classification • 1) thoracictype • 2) lumbar type
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  Thoracic type • Purethoracic:- apex at mid thoracic spine • When kyphosis <750 , chance of progression is less without significant pain • When >800 continues to progress with increased pain • Common in adolescent as well as adult • Thoracolumbar pattern with its apex at thoracolumbar Jn has high propensity to progress and can be significantly painful.
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  Lumbar type • Generallymales with back apin • Benign prognosis
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  Differential diagnosis • posturalkyphosis
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  Treatment
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  Non operative treatment Indications •Relative skeletal immaturity ( </= rise grade II) and a progressive deformity that cosmetically or functionally unacceptable ( usually >600) Goals • To control the deformity • To reconstitute the anterior vertebral height by applying hyper extension forces
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  Modalities • Anti-inflammatory medications •Exercises • Bracing
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  • Apical vertebraat or above T7 : Milwaukee brace • Apical vertebra below T7 : thorocolumbar sacral orthosis (TLSO), usually supplemented with anterior sternal or infraclavicular outtriggers • With a decrease in lumbar lordosis, patient encouraged to actively hyperextend the spine to maintain the head in a more upright position • Initially bracing is recommended for 18 hours a day, radiographs every 6 months. • Brace treatment continue until skeletal maturity.
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  TLSO MILWAUKEE BRACE
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  Cast treatment • Whenpassive correction on lateral bolster radiograph is <40%, brace TX is not likely to be effective • Need total compliance and desire of the adolescent to achieve correction • Risser casts applied in a serial fashion to produce more correction • Following 6-9 month period of casting , then treated with Milwaukee brace or other brace to maintain the correction upto skeletal maturity
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  Surgical management Indications • Kyphosis:>80o in T spine, >650 in T-L spine • Symptomatic ( pain, neurologic deficit, cosmetic) of T spine > 750 or T- L spine >600 not controlled by non operative methods • Significant sagittal imbalance
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  Determining level offusion • From standing lateral radiograph • Upper limit must include most proximal vertebra that is tilted into the kyphosis, generally upto T2 • Caudal should include first lordotic disk space, commonly includes one level distal to thee measured end vertebra of kyphosis
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  Surgical technique options
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  Anterior release andfusion • Indication : when kyphosis is rigid on hyperextension films • Level of anterior release:include the rigid apical based on hyperextension films • Technique: right sided thoracotomy / thoracoscopic • Procedure: disc spaces exposed and curetted preserving the bony endplate, bone graft placed at each disc space
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  Posterior instrumented correction •Done as standalone / combined with anterior procedure • Either single /staged procedure
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  posterior instrumentation alone •skeletally immature ( risser grade III) and has some anterior growth potential remaining and if the kyphosis is corrected to <500 on hyperextension lateral film • chances of loss of correction is high
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  Principle of posteriorinstrumentation • Correcting maneuver used is cantilevering the rod on to spine and segmental compression from apex to ends • Include minimum of 8 anchors above and below the apex • 3-5 pairs of pedicle hook- transverse process claws cephalad and similar number of pedicle screws caudal to apex
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  Surgical technique • LUQUEinstrumentation: degmental sublaminar wiring • Multisegmnet hook rod system • Pedicle screw system • Harrington rod system • amount of correction achieved increased by osteotomizing the facets, excising the ligamnetum flavum( PONTE OSTEOTOMY)
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