IDIOPATHIC SCOLIOSIS INTRODUCTION DIAGNOSIS TREATMENT

SCOLIOSIS

1. IDIOPATHIC SCOLIOSIS Dr. Mit Parikh

2. DEFINTION A three-dimensional deformity occurs in three planes Frontal Sagittal Axial

3. • END VERTEBRA : • APICAL VERTEBRA : • NEUTRAL VERTEBRA : • STABLE VERTEBRA : • CURVE DIRECTION : right curves are the curves convex to right side. • CURVE LOCATION :scoliotic curve is termed based on its apex.

4. IDIOPATHIC SCOLIOSIS Most common F>M

5. Infantile scoliosis Age M>F Left thoracic curve pattern is most common Two types have been identified: A resolving type (85%) and a progressive type (15%) PATHOANATOMY Intra uterine packing disorder Environmental Genetic

6. 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

7. CLINICAL FEATURE

8. 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 the convex side Increased flank creases – concave side Higher ASIS PSIS – concave side

9. Diagnosis RVAD > 20° is linked to a high rate of progression < 20° is associated with spontaneous recovery

10. 2. RVA phase 1 - no rib overlap phase 2 - rib overlap with the apical vertebrae high risk for curve progression

11. 3. CURVE MAGNITUDE : Cobb’s angle > 20 degrees associated with progression

12. Nonoperative observation alone (most resolve spontaneously) indications Cobb angle < 20° RVAD < 20° 90% will resolve spontaneously

13. SERIAL MEHTA CASTING (DEROTATIONAL) OR THORACOLUMBOSACRAL ORTHOSIS (TLSO)     INDICATIONS F lexible curves Cobb angle > 20° RVAD > 20° P hase 2 rib-vertebrae relationship (rib-vertebral overlap) MECHANISM F unctions to straighten the spine in young patients I n older patients it serves as an adjunctive measure prior to definitive treatment

14. COMPLICATIONS Cast syndrome Neurological deficit Plaster sores Respi insuff . Secondary rib deformities Cast changes are done based on the child’s growth rate with changes in every 2 months for those aged 2 years and below, 3 months for those aged 3 years and 4 months for those aged 4 years and above. A curve of less than 10-degree supine out of cast is the end point at which a well-molded brace is given.

15. BRACING INDICATIONS incompletely corrected curves after Mehta casting late presenting cases where the spine is still flexible. TYPES CTLSO (cervical-thoracic-lumber-sacral orthosis) – Milwaukee brace TLSO (Thoracic-Lumber-Sacral Orthosis) – Boston brace Overcorrecting brace – Charleston and Providence

16. PROBLEMS Poor compliance Adverse psychological reaction In older JIS exacerbation of pre-existing gastro-esophageal reflex Severe asthma eczema chest wall deformity

17. INDICATIONS FOR SURGICAL TREATMENT Curves more than 50 degree Curves that fails to respond to casting/bracing. GOAL slow or stop the curve progression, which allows maximum growth of the spine, lungs, and the thoracic cage.

18. GROWING ROD SYSTEMS

19. 2. MAGNETIC GROWTH RODS

20. 3. VEPTR – CHEST WALL DISTRACTION SYSTEMS

21. 4. ANTERIOR VERTEBRAL STAPLES HUETER-VOLKMAN LAW

22. 5. ANTERIOR VERTEBRAL BODY TETHERING

23. CRANKSHAFT PHENOMENON

24. 6. SHILLA PROCEDURE

25. ADOLESCENT IDIOPATHIC SCOLIOSIS Most common type. Male:female:1:6 Curve type: right thoracic Risk of cardiopulmonary compromise low Rate of curve progression: 1 to 2 degrees/month

26. FACTORS INVOLVED IN THE DEVELOPMENT Structural (radiographically Cobb angle of 25° or more on ipsilateral side- bending radiographic views) Non- structural - compensatory and postural

27. RISSER SIGN: to asses the growth potential of the child. It describes the ossification of the iliac apophysis. It ossifies from lateral to medial. • Grade 0: absent • Grade 1: 0-25 % • Grade 2 : 26 -50% • Grade 3 : 51 – 75 % • Grade 4: 76 – 100 % • Grade 5 : fusion of apophysis to the ilium. GRADE 0 and 1 : rapid curve progression GRADE 4 : end of spinal growth in females GRADE 5: end of spinal growth in males

28. CLINICAL FEATURE BACK PAIN PULMONARY PROBLEMS PSYCHOSOCIAL PROBLEMS Uneven shoulders. One shoulder blade that appears more prominent than the other. Uneven waist. One hip higher than the other. One side of the rib cage jutting forward. A prominence on one side of the back when bending forward.

29. DIAGNOSIS

30. RADIOGRAPH COBB ANGLE

31. MANAGEMENT CONSERVATIVE INDICATION Risser 0-2 Major curve Cobb 25-30 degree Pre- menarchal or less than 1 year 4. Post menarchal with curve progression 5-10 degrees in 6 months MILWAUKEE BRACE BOSTON BRACE

32. 2. SURGICAL INDICATION Curve with cobb exceeding 40 degree Curve with documented progression Patient with significant growth potential Thoracic lordosis Cosmetic concern for deformity

33. THORACIC / LUMBER FUSION

34. COMPLICATIONS INFECTION SPINAL CORD INJURY SCREW MISPLACEMENT VISCREL INJURY IN CASE OF THORACIC SCOLIOTIC CURVE VASCULAR INJURY LONG TERM PSEUDOARTHROSIS IMPLANT BREAKAGE ADDING ON PHENOMENON

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