Deformities of spine

deformities of spine-scoliosis,kyphosis,lordosis

1. DEFORMITIES OF SPINE CHAIRPERSON-DR.S.K SAIDAPUR PRESENTER-DR.AAYUSH ARORA

2. SPINAL CORD DEFORMITIES- 1)SCOLIOSIS 2)KYPHOSIS 3)LORDOSIS

3. SCOLIOSIS- Is defined as a lateral deviation of the normal vertical line of the spine. The lateral curvature of the spine also is associated with rotation of the vertebrae. This produces a three-dimensional deformity of the spine that occurs in the sagittal, frontal, and coronal planes.

4. ANATOMY- All the bony elements are altered- 1)vertebra are wedge shaped 2)Poorly developed concave side 3)Pedicle rotated

5. Infantile scoliosis occurs from birth to 3 years of age; juvenile idiopathic scoliosis, between the ages of 4 and 10 years; and adolescent idiopathic scoliosis, between 10 years of age and skeletal maturity. Scoliosis also can be classified based on the cause and associated conditions. Idiopathic scoliosis is the most common type.Congenital scoliosis is caused by a failure in vertebral formation or segmentation of the involved vertebrae.

6. INFANTILE IDIOPATHIC SCOLIOSIS- Infantile idiopathic scoliosis is a structural, lateral curvature of the spine occurring in patients younger than age 3 years . Most curves in infantile idiopathic scoliosis are selflimiting and spontaneously resolve (70% to 90%); however,some curves may be progressive, usually increasing rapidly,are often difficult to manage, and may result in significant deformity and pulmonary impairment.

7. It is reported that 84 % of the curves progressed if the RVAD was greater than 20 degrees. TREATMENT- Because of the favorable natural history in 70% to 90% of patients with infantile idiopathic scoliosis, active treatment often is not required. If the initial curve is less than 25 degrees and the RVAD is less than 20 degrees, observation with radiographic follow-up every 6 months is recommended.Most resolving curves correct by 3 years of age

8. AT 3 YEARS AGE AT 6 YEARS AGE AT 10 YEARS AGE

9. Treatment options for children with progressive infantile idiopathic scoliosis curves include serial casting, bracing, and later fusion; preoperative traction to correct the curve followed by fusion; and growing rod or vertical expandable prosthetic titanium rib (VEPTR) instrumentation without fusion.

10. BEFORE APPLYING CAST AFTER 9 MONTHS OF CAST

11. GROWTH RODS- Commanly used in childrens . Allow for straightning of spine and subsequent lengthening procedure until adolescence when a final fusion is performed.

12. JUVENILE IDIOPATHIC SCOLIOSIS- Juvenile idiopathic scoliosis appears between the ages of 4 and 10 years . It was found that 67% of patients younger than age 10 years showed curve progression and that the risk of progression was 100% in patients younger than 10 years who had curves of more than 20 degrees.

13. For curves of less than 20 degrees, observation is indicated, with examination and standing posteroanterior radiographs every 4 to 6 months. Evidence of progression on the radiographs as indicated by a change of at least 5 to 7 degrees warrants brace treatment. The success of nonoperative treatment is variable; 27% to 56 % require spinal fusion for progressive curves.

14. It found that patients who wore a brace part time (after school and at night) had good outcomes with curves of less than 35 degrees and RVADs of less than 20 degrees. Patients with curvatures of greater than 45 degrees at the onset of bracing and whose RVADs exceeded 20 degrees all eventually underwent spinal fusion .

15. Another important consideration is the 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, causing loss of correction, increase in vertebral rotation, and recurrence of the rib hump.

16. CRANKSHAFT PHENOMENA

17. ADOLESCENT IDIOPATHIC SCOLIOSIS- Adolescent idiopathic scoliosis is present when the spinal deformity is recognized after the child is 10 years of age but before skeletal maturity. This is the most common type of idiopathic scoliosis. The characteristics of adolescent idiopathic scoliosis include a three-dimensional deformity of the spine with lateral curvature plus rotation of the vertebral bodies .

18. ETIOLOGY- ( 1) Genetic factors ( 2) Neurologic disorders ( 3) Hormonal and metabolic dysfunctions ( 4) Skeletal growth (5 ) Biomechanical factors (6 ) Environmental and lifestyle factors

19. The effect of progressive curves on adults with untreated scoliosis has been studied by several investigators. Four major considerations in the natural history of untreated adolescent idiopathic scoliosis in adults are- 1)Back pain-The incidence of frequent daily backache is slightly higher in patients with scoliosis (80 % to 86%) than in patients without scoliosis. 2)Pulmonary function-A direct correlation has been noted between decreasing vital capacity and increasing curve severity. 3 )Curve progression-In contrast, lumbar and thoracolumbar curves may arise in adult life and cause severe pain and discomfort.

20. 4)Mortality- Death in patients with adult idiopathic scoliosis also seems to be related to thoracic curves greater than 100 degrees , with resultant cor pulmonale . The scoliometer can be used in conjunction with the Adams forward bending test to evaluate truncal rotation . An angle of less than 7 degrees is considered within the limits of normal, and an angle of more than 7 degrees usually is associated with a curve of 15 to 20 degrees.

21. KING CLASSIFICATION It is used to describe thoracic curves and aid in determining when the thoracic curve alone or both the thoracic and lumbar curves should be included in the instrumentation and fusion.

22. The two most widely accepted nonoperative techniques for idiopathic scoliosis are observation and bracing . Indications for Operative Treatment of Idiopathic Scoliosis- 1)Increasing curve in growing child 2)Severe deformity (> 50 degrees) with asymmetry of trunk in adolescent 3)Pain uncontrolled by nonoperative treatment 4)Thoracic lordosis 5)Significant cosmetic deformity

23. KYPHOSIS- In the sagittal plane, the normal spine has four balanced curves : the cervical spine is lordotic ; the thoracic spine is kyphotic (20 to 50 degrees), with the curve extending from T2 or T3 to T12; the lumbar region is lordotic (31 to 79 degrees ); and the sacral curve is kyphotic . On standing, the thoracic kyphosis and lumbar lordosis are balanced .

24. Kyphosis of 50 degrees or more in the thoracic spine usually is considered abnormal. Kyphotic deformity may occur if the anterior spinal column is unable to withstand compression, causing shortening of the anterior column.

25. 3 TYPES OF KYPHOSIS- 1)POSTURAL KYPHOSIS 2)SCHEUERMANN KYPHOSIS 3)CONGENITAL KYPHOSIS

26. POSTURAL KYPHOSIS- It is most comman type of kyphosis. More comman in girls than in boys. It is caused by weakining of muscles and poor posuture It progressively gets worsed with time. These people will have symptoms of pain and muscle fatigue .

27. Scheuermann Kyphosis- Scheuermann kyphosis is a structural sagittal plane deformity in the thoracic or the thoracolumbar spine . Patients have an increased kyphosis in the thoracic or thoracolumbar spine with associated diagnostic radiographic changes. Normal thoracic kyphosis is generally accepted to be between 20 and 45 °. The degree of kyphosis in the thoracic spine increases with age. Kyphosis should never be present at the thoracolumbar junction. Any kyphotic deformity present at this level is considered abnormal.

28. The two types of thoracic Scheuermann kyphosis are kyphosis with the apex at the T7-T9 level and kyphosis with the apex in the lower thoracic spine at the thoracolumbar junction (T11-T12 ). Clinically, most patients with thoracic Scheuermann kyphosis present with a history of deformity, the chief complaint is generally that of pain (80%). The pain is usually intermittent in nature.It is characterized as dull and aching and is generally activity related and relieved by rest

29. On physical examination, patients with upper thoracic Scheuermann disease present with a kyphotic deformity. This is best demonstrated in the forward flexed position.

30. The radiographic diagnosis of Scheuermann kyphosis is made by the presence of irregularities of the vertebral endplates, anterior vertebral body wedging , Schmorl nodes, and decreased intervertebral disc space height.

31. NONOPERATIVE TREATMENT- OBSERVATION- Adolescents with mildly increased kyphosis of less than 50 degrees without evidence of progression can be evaluated with repeated standing lateral radiographs every 4 to 6 months.

32. OPERATIVE TREATMENT- The indications for surgery in patients with Scheuermann kyphosis are a progressive kyphosis of more than 75 degrees and significant kyphosis associated with pain that is not alleviated by conservative treatment methods. The biomechanical principles of correction of kyphosis include lengthening the anterior column (anterior release), providing anterior support ( interbody fusion), and shortening and stabilizing the posterior column (compression instrumentation and arthrodesis)

33. CONGENITAL KYPHOSIS- Congenital kyphosis occurs because of abnormal development of the vertebrae consisting of a failure of formation or failure of segmentation of the developing segments . Congenital kyphosis of three types. Type I is congenital failure of vertebral body formation. Type II is failure of vertebral body segmentation. Type III is a combination of both of these conditions.

34. TYPE 1 TYPE 2 TYPE 3

35. OPERATIVE TREATMENT- The natural history of this condition usually is one of continued progression and an increased risk of neurologic compromise.Therefore surgery is the preferred method of treatment . The treatment of type I deformity depends on the stage of the disease . For type I deformity, the best treatment is early posterior fusion. In a patient younger than 5 years old with a deformity of less than 50 or 55 degrees, posterior fusion alone, extending from one level above the kyphotic deformity to one level below, is recommended.

36. If the deformity is more than 55 degrees, anterior and posterior fusion produces more reliable results . If a type II kyphosis is mild (<50 degrees) and detected early, posterior fusion using compression instrumentation can be done. If the deformity is severe and detected late, correction can be obtained only with anterior osteotomies and fusion, followed by posterior fusion and compression instrumentation.

37. LORDOSIS- It is an inward curvature of a portion of lumbar or cervical vertebra column. It may be due to achondroplasia and spondylolisthesis . It is associated with poor posture,a congenital problem with vertebra,neuromuscular problem and back surgery In childrens,rickets may lead to lordosis .

38. Clinical features- 1)Prominence of buttock 2)Back pain 3)Pain radiating to lower limb

39. TREATMENT- Based on- Childs age, overall health, medical history, cause and extent of the condition. Goal of treatment is to stop the progression of the curve, prevent deformity. Simple exercises are sufficient , If Lordosis is associated with poor posture

40. PROGNOSIS- Prognosis depends on child's age, amount of curvature Requires frequent examination by the physician to monitor curve as the child grows and develop. Early detection helps in proper management.