Idiopathic scoliosis

Idiopathic Scoliosis. Orthopedic Undergraduate.

1. Idiopathic Scoliosis Presented By Siti Nur Rifhan Kamaruddin

2. OVERVIEW Definition : A spinal deformity characterized by lateral bending and fixed rotation of the spine in the absence of any cause. This groups constitutes about 80% of all cases of scoliosis In general, the younger the age at onset, the more likely the deformity will progress and require treatment The deformity is often familial Age of onset : - Early Onset : Before puberty - Late Onset : After puberty

3. ETIOLOGY Remains unknown Several studies have suggested : - Genetic cause - Tissue deficiencies - Vertebral growth abnormalities - Central nervous system theories.

4. CLASSIFICATION Based on Curve Location : Cervical Apex : C2-C6 Cervicothoraxic Apex : C7-T1 Thoraxic Apex: T2-T12 Thoracolumbar Apex : T12-L1 Lumbar Apex : L2-L4

5. Based on Age at Onset Age of Onset : Infantile : Age birth to 3 years Juvenile : Age 4 to 10 years Adolescent : Age 11- 17 years (the most common)

6. CLINICAL FEATURES Pain : Not a common complaint Discomfort can be a common feature but not severe pain Mild back discomfort and fatigue in 23% of cases. If severe pain : Must question etiology of the idiopathic curve.

7. Adolescent IDIOPATHIC SCOLIOSIS Commonest type . Mostly in girls Primary thoraxic curves are usually convex to the right , lumbar curves to the left. Most curves < 20% : either resolve spontaneously or remain unchanged Once a curve start progress, it usually goes on doing throughout growth period. Progression predictors : - Very young age - Marked curvature - An incomplete Risser sign at presentation

8. TREATMENT For Adolescent Idiopathic Scoliosis Aim: To prevent progression To correct deformity Based on : Skeletal maturity : Risser stage Curve magnitude : Cobb’s angle Curve progression : Observation Treatment Options : The Three O’s Observation Osthoses Operation

9. The  Risser sign  is an indirect measure of skeletal maturity, whereby the ossification stage of the Iliac apophysis is used to judge the ossification of the spinal vertebrae The earlier the Risser Grade, the greater the likelihood of a scoliosis progressing to the point it becomes clinically significant and requires intervention.

10. 1.OBSERVATION The aim of observation for Adolescent idiopathic scoliosis is to identify and document the curve progression Curves less than 20° are observed.

11. 2. ORTHOTIC TREATMENT Spinal orthotic is used to prevent curve progression and generally, does not lead to permanent curve improvement. Although bracing is still being used, it is now recognized that it does not actually improve curve – at best, it just stops it from getting worse. Preference now : Wait for the curve to progress to the stage where corrective surgery would be justified.

12. Contraindication for Brace treatment Skeletally mature patients Curves greater than 40° Thoracic lordosis ( Bracing potentiates cardiopulmonary restriction) Patient unable to cope emotionally with treatment

13. Type of Brace CTLSO ( Milwaukee Brace) : Consist of a pelvic corset connected by adjustable steel supports to a cervical ring carrying occipital & chin pa ds. Used less commonly due to its cosmetic appearance. Aim: Reduce lumbar lordosis & encourage stretching & straightening of thoracic spine. TLSO (i.e. Boston brace): Snug-fitting underarm brace. Provide lumbar or lower thoracolumbar support. A re better accepted by Pts. Indicated for curves with an apex T8 or below. Bending brace (i.e. Charleston brace). It is worn only during sleep. This type holds the Pt in an acutely bent position in a direction opposite to the curve apex. Flexible brace (i.e. SpinCor brace)

14. Milwaukee Brace Charleston Brace SpineCor Brace Boston Brace

15. 3. OPERATION Objectives : To halt progression of the deformity To straighten the curve To anthrodese the primary curve by bone grafting. Indications: Curves greater than 30° that are cosmetically unacceptable esp. in prepubertal children Milder deformity that is deteriorating rapidly

16. Operative/Surgery Options The Harrington System - The old, original system. A rod was applied posteriorly along the concave side of curve- attached to the rod were movable hooks that were engaged in the uppermost & lowermost vertebrae to distract the curve. Major Disadvantage: It does not correct the rotational deformity- rib prominence remains unchanged.

17. Rod and Sublaminar Wiring ( Luque ) Modified Harrington System Wires are passed under vertebral laminae at multiple levels and fixed to the rod at concave side of curve. – provides more controlled, secure fixation Disadvantage: Because the wires are dangerously close to the dura -> increase risk of neurological damage

18. The Cotrel-Dubousset System This method combines a pedicle screw box foundation at the caudal end of deformity With multiple hooks placed at various levels to produce either distraction or compression. Using double rods can distract on the concave and compress on the convex side of the curve . Claimed that this method can correct rotational deformity as well. It is sufficiently rigid to make postoperative bracing unnecessary .

19. Anterior instrumentation This method approaches the spine from the front. It removes the discs throughout the curve & then applying a compression device along convex side of curve. Bone grafts added to achieve fusion. Advantages - It provides strong fixation with less vertebral segment to be fused. - Less risk of cord injury

20. COMPLICATIONS OF SURGERY Neurological compromise - With modern techniques, the incidence of permanent paralysis has been reduced to less <1% Spinal Decompression - Over correction may produce an unbalanced spine. - This should be avoided by careful preoperative planning. Implant Failure - Hooks may cut out and rods may break. If this is assoc. a symptomatic pseudarthrosis, revision surgery will be needed.

21. EARLY ONSET IDIOPATHIC SCOLIOSIS (INFANTILE) (< 3 YEARS) Rare – Most babies nowadays are allowed to sleep prone Male predominance Left thoracic curve pattern is most common 90% of infantile scoliosis resolves spontaneously Association with plagiocephaly, developmental delay, CHD and DDH.

22. Treatment for Infantile Id. Scoliosis Due to the favorable natural history in 70% to 90% of patients with infantile idiopathic scoliosis, active treatment often is not required. Resolving curves - Most correct by 3 years age. observed with serial physical examinations and radiographic monitoring. (may recur in adolescence) Sleeping in the prone position is recommended Progressive curves are treated with serial casting followed by orthotic treatment with a Milwaukee brace The interval between cast changes is determined by the rate of the child’s growth, but a cast change usually is required every 2 to 3 months Surgery : posterior spinal instrumentation without fusion or the vertically expandable prosthetic titanium rib (VEPTR).

23. A : Position on table with traction applied to halter and pelvis . B: Example of correction maneuver for de-rotation of left thoracic curve. C : Underarm cast with windows .

24. EARLY ONSET IDIOPATHIC SCOLIOSIS (JUVENILE) (AGED 4-9 YEARS) Less common than adolescent type. Increasing female predominance Most common curve patterns are right thoracic. Prognosis is worse : 70% of curves progress and require treatment (surgery or bracing) If the child is very young, a brace may hold temporarily until Age 10, when fusion is likely to succeed.

25. Treatment of Juvenile Id. Scoliosis Juvenile idiopathic scoliosis is treated according to guidelines similar to those for adolescent idiopathic scoliosis. Curve < 20°: Observation with examination and standing posteroanterior radiographs every 4-6 months. Evidence of progression on the radiographs as indicated by a change of at least 5 to 7 degrees warrants brace treatment. If the curve is not progressing, observation is continued until skeletal maturity. Curve 25° to 50° range : Orthotic treatment Curve > 50° : Surgery

26. REFERENCES Apley and Solomon’s Concise System of Orthopedics and Trauma 4 th Edition. CRC Press