KYPHOSIS.pptx KYPHOSIS DEFORMITY OF THE SPINE

KYPHOSIS DEFORMITY OF THE SPINE

1. KYPHOSIS Dr.M.NAGENDRABABU PROF Dr.K .RAMKUMAR REDDY ASSOC PROF Dr .T.KONER RAO ASST PROF Dr.R.JAISINGH ASST PROF DR. K Venkat Santosh Reddy PG MS[ ORTHO] Moderators Presentation by 9/20/2013 1 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL

2. 9/20/2013 2 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL KYPHOSIS ETIOLOGY DIAGNOSIS MANAGEMENT

3. Cervical Lordosis 20°- 40° Sacral Kyphosis Lumbar Lordosis 30°- 50° Thoracic Kyphosis 20°- 40° Sagittal Plane Curves

4. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 4 KYPHOSIS Kyphosis of 50 degrees or more in the thoracic spine usually is considered abnormal. deformity may occur if the anterior spinal column is unable to withstand compression, causing shortening of the anterior column. Disruption of the posterior column and inability to resist tension can lead to relative lengthening of the posterior column and kyphosis

5. 9/20/2013 5 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL SAGITTAL BALANCE Overall spinal sagittal balance is determined by a plumb line dropped from the dens. plumb line usually is dropped from the middle of the C7 vertebral body. This plumb line usually falls anterior to the thoracic spine, posterior to the lumbar spine, and through the posterior superior corner of S1 Positive sagittal balance occurs when the plumb line falls in front of the sacrum, negative sagittal balance occurs when the plumb line falls behind the sacrum.

6. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 6 for sagittal balance to be maintained, lumbar lordosis should measure 20 to 30 degrees more than the kyphosis . The lumbar lordosis is a dependent variable based on the amount of kyphosis .

7. 9/20/2013 7 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL The thorasic kyphosis begins at the first thoracic vertebrae maximal segmental kyphosis at T6 or T7. The normal apex of this lordosis is at the vertebral body of L3 or L4 or the disc space itself. The segments at L4-5 and L5-S1 account for 60% of the overall lumbar lordosis . the lumbar discs account for −47 degrees of the lordosis ; the vertebral bodies −12 degrees. This emphasizes the importance of preserving disc height during anterior proce-dures for the treatment of spinal deformities.

8. 9/20/2013 8 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL Thoracolumbar junction A transition from relatively rigid kyphotic thoracic spine to a relatively mobile lordotic lumbar spine. It is nearly straight. This relationship must be maintained during reconstructive procedures to prevent a junctional kyphosis .

9. 9/20/2013 9 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL Postural, Scheuermann disease Congenital ,Defect of segmentation Defect of formation, Mixed Paralytic Poliomyelitis Upper motor neuron Myelomeningocele Posttraumatic Acute, Chronic Inflammatory Tuberculosis Other infections Ankylosing spondylitis Causes of kyphosis

10. 9/20/2013 10 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL Metabolic Osteoporosis Osteogenesis imperfecta Developmental, Achondroplasia Mucopolysaccharidoses Tumor. Postsurgical Postlaminectomy Postexcision ( eg , tumor) Postradiation

11. 9/20/2013 11 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL SCHEUERMANN DISEASE Scheuermann originally described a rigid juvenile kyphosis in 1920. Scheuermann disease is a structural kyphosis of the thoracic or thoracolumbar spine that occurs in 0.4% to 8.3% of the general population. slightly more often in male s. The age at onset –during prepubertal growth spurt, between 10 and 12 years of age.

12. 9/20/2013 12 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL CLASSIFICATION deter-mined by the location and natural history of the kyphosis TYPICAL FORM ATYPICAL FORM. thoracolumbar junction or the lumbar spine involves the thoracic spine. kyphosis has three or more consecutive vertebrae, each wedged 5 degrees or more, producing a structural kyphosis . Most common characterized by vertebral endplate changes, disc space narrowing, and anterior Schmorl nodes

13. 9/20/2013 13 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL ETIOLOGY multifactorial . Scheuermann - osteo -necrosis of the ring apophysis of the vertebral body. Schmorl – herniation of disc material into the vertebral body; . Ferguson- persistence of anterior vascular grooves in the vertebral bodies Bradford and Moe osteoporosis may be responsible for the development of Scheuer-mann disease.

14. 9/20/2013 14 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL A biochemical abnormality of the collagen and matrix of the vertebral endplate cartilage also has been suggested genetic basis for Scheuermann disease. The disease may be inherited in an autosomal -dominant fashion.

15. 9/20/2013 15 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL CLINICAL FINDINGS TYPICAL appears around the adolescent growth spurt. The presenting complaint pain in the middle or lower back or concern about posture. worse by activity, and typically improves with the cessation of growth. Physical examination shows an angular thoracic or tho - racolumbar kyphosis with compensatory hyperlordosis of the lumbar spine. The kyphosis is sharply angular and does not correct with the prone extension tes t The lumbar lordosis below the kyphosis usually is flexible and corrects with forward bending.

16. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 16 Atypical (lumbar) low back pain, they do not have as noticeable a deformity. Pain with spinal movement is the primary symptom.

17. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 17 RADIOGRAPHIC FINDINGS The amount of kyphosis is determined by the Cobb method on a lateral radiograph of the spine. The criteria for the diagnosis more than 5 degrees of wedging of at least three adjacent vertebrae at the apex and vertebral endplate irregularities with a thoracic kyphosis of more than 50 degrees Bradford suggested that three wedged vertebrae are not necessary for the diagno - sis but rather an abnormal, rigid kyphosis is indicative of Scheuermann disease. Flexibility and the structural nature of the deformity are determined by taking a lateral posteroan - terior radiograph with the patient lying over a bolster placed at the apex

18. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 18 On a lateral radiograph, most patients will be in negative sagittal BALANCE Atypical Scheuermann disease irregularity of the vertebral endplates, presence of Schmorl nodes, and narrowing of the intervertebradiscs ,

19. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 19 NATURAL HISTORY In most cases - minimal deformity and few symptoms . can progress rapidly during the adolescent growth spurt. Factors that contribute to the risk of continued progression of kyphosis include the number of years of growth remaining and the number of wedged vertebrae. Lumbar Scheuermann disease, usually is associ ated with strenuous physical activity , generally becomes asymptomatic within several months after restriction of activities. It has not been shown to have any long-term sequelae in adult life, as long as those affected avoid strenu - ous jobs.

20. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 20 ASSOCIATED CONDITIONS Mild-to-moderate scoliosis (10 to 20 degrees). usually has a benign natural history Lumbar spondylolysis . The suggested reason for the increased incidence of spondylolysis (50% to54%) is that increased stress is placed on the pars intraarticu-laris because of the associated compensatory hyperlordosis of the lumbar spine disease include endocrine abnormalities, hypovitaminosis , inflammatory disorders, and dural cyst

21. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 21 TREATMENT The indications pain, progression of deformity, neurological compromise, cardio-pulmonary compromise, and cosmesis . Treatment options observation, conservative methods, and surgery

22. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 22 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. When growth is complete, further follow-up is not needed.. An exercise program,can help maintain flexibility, correct lumbar lordosis , and strengthen the extensor muscles of the spine and may improve any postural component of the deformity. Stretching exercises should be prescribed for patients with associated tightness of the hamstring or pectoralis muscles.

23. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 23 ORTHOTIC TREATMENT The Milwaukee brace is recommended This brace acts as a dynamic three-point orthosis that promotes extension of the thoracic spine. Indications at least 1 year of growth remaining in the spine, some flexibility of curve (40% to 50%), and kyphosis of more than 50 degrees The brace is worn full time for the first 12 to 18 months. If the curve has stabilized and no progression is noted, then a part-time brace program can be used until skeletal maturity. Boston lumbar kyphosis orthosis was satisfactory for correction of curves of less than 70 degrees and had better compliance. .

24. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 24 Boston brace Milwakee brace

25. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 25 Scoliosis cast

26. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 26 The rationale for the Boston lumbar orthosis is that reduction of the lumbar lordosis will cause the patient to dynamically straighten the thoracic kyphosis to maintain an upright posture. This presupposes a flexible kyphosis , the absence of hip flexion contractures. Lowe used a modified underarm TLSO for patients with thoracolumbar -pattern Scheuermann disease (apex T9 and below) and found that it was as effective as the Milwaukee brace and was cosmetically more acceptable to patients.\ Hyperextension casting has been used with excellent results problems with the skin, restrictions of phys- ical activity, and the need for frequent cast changes

27. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 27   OPERATIVE TREATMENT The indications progressive kyphosis of more than 75 degrees and significant kyphosis associated with pain . The biomechanical principles lengthening the anterior column (anterior release), providing anterior support ( interbody fusion), and shortening and stabilizing the posterior column (compression instrumentation and arthrodesis ).

28. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 28 The combined anterior and posterior approach has been the most frequently recommended. the development of pedicle screw fixation and posterior spinal osteotomy techniques, such as the Ponte procedure, For shortening and stabilizing the posterior column A posterior procedure without osteotomy can be con- sidered if the kyphosis is flexible and can be corrected to, and maintained at, less than 50 degrees while a posterior fusion occurs.

29. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 29 Historically, the use of Harrington compression rods was common, but these have been replaced by segmental hook and pedicle screw instrumentation.

30. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 30 Posterior fusion and instrumentation should include …. the proximal vertebra in the measured kyphotic deformity and the first lordotic disc distally. If the fusion and instrumentation end in the kyphotic deformity, a junctional kyphosis at the end of the instrumentation may occur. Overcorrection of the deformity should be avoided to prevent junctional kyphosis . No more than 50% of the preoperative kyphosis should be cor - rected , and the final kyphosis should not be less than 40 degrees.

31. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 31 1.Anterior Release and Fusion . Release the anterior longitudinal ligament and excise the entire disc and cartilaginous end plate, leaving only the posterior portion of the anulus and the posterior longitudinal ligament interbody fusion with use of the rib graft

32. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 32 Posterior Multihook and Screw Segmental Instrumentation The standard method consists of inserting the precontoured rod into the pedicle–transverse process claws above the apex of the kyphosis . The distal end of the rod is then pushed into the lower spine with a rod pusher. rigid POSTERIOR FIXATION systems, combined with extensive resection of laminae and posterior joints carried out thoroughly, can lead to a posterior shortening of the kyphosis and correction of the kyphosis without the need of anterior release and fusion

33. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 33 Posterior Column Shortening Procedure for Scheuermann Kyphosis The potential advantages of this technique include that it is a single-stage posterior procedure; the posterior spine is shortened rather than the anterior spine lengthened, thereby increasing safety;; and there is no surgical interference with anterior blood supply to the spinal cord . A, Broad posterior resection (shaded parts) at every intersegmental level of entire area of fusion and instrumentation. B, Posterior view showing levels of completed resections. C, Lateral view showing gaps from osteotomies . Correction is achieved by closing gaps. D, Oblique view showing three apical vertebrae after completion of bone resections. Apical vertebra is left uninstrumented .

34. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 34 CONGENITAL KYPHOSIS abnormal development of the vertebrae consisting of a failure of formation or failure of segmentation of the developing segments leads to cong.kyphosos 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. McMaster and Singh further subdivided type I congenital kyphosis into posterolateral quadrant vertebrae, posterior hemivertebrae , Butterfly ( sagittal cleft) vertebrae, and anterior or anterolateral wedged vertebrae This classification is important in predicting the natural history of these congenital kyphotic deformities.

35. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 35 Any classification can be further subdivided into deformities with or without neurological compromise .

36. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 36 Type I deformities are more common than type II deformities and occur more com- monly in the thoracic spine and at the thoracolumbar junc - tion . They are extremely rare in the cervical spine. progression was most rapid in type III kyphosis , followed by type I ….. An anterior failure of vertebral body formation produces a sharply angular kyphosis that is much more deforming and potentially dangerous neurologically than a curve with a similar Cobb measurement.

37. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 37 Type II deformities (failure of segmentation) are less common. these deformities progress at an average rate of 5 degrees a year and are not as severe as type I deformities. Paraplegia usually is not reported in patients with type II kyphosis ; however, low back pain and cosmetic deformities are significant and early treatment is warranted.

38. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 38 CLINICAL and RADIOLOGICAL EVALUATION detected before birth on a prenatal ultrasound examination or noted as a clinical deformity in a neonate. If the deformity is mild, congenital kyphosis can be overlooked until a rapid growth spurt makes the condition more obvious. Physical examination usually reveals a kyphotic deformity at the thoracolumbar junction or in the lower thoracic difficult to detect on early films because of incomplete ossification. Flexion and extension lateral radiographs are helpful in determining the rigidity of the kyphosis and possible instability of the spine. CT with three-dimensional reconstructions can identify the amount of vertebral body involvement and can determine whether more kyphosis or scoliosis might be expected

39. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 39 An MRI study should be obtained in most patients because of the significant incidence of intraspinal abnormalities.. Genitourinary abnormalities, cardiac abnormalities, Klippel-Feil syndrome, and intraspinal abnormalities are fre - quent in these patients. Cardiac evaluation and renal ultraso - nography should be done.

40. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 40 OPERATIVE TREATMENT The natural history of this condition usually is one of continued progression and an increased risk of neurological compromise . Therefore, surgery is the preferred method of treatment. bracing has no role in the treatment of congenital kyphosis type of surgery depends on the type and size of the deformity, the age of the patient, and the presence of neurological deficits. Procedures include posterior fusion, anterior fusion, combined anterior and posterior fusion, and anterior osteotomy with posterior fusion.

41. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 41 TREATMENT OF TYPE I DEFORMITY the best treatment is . 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, allows for some improvement because growth continues anteriorly from the anterior endplates of the vertebrae one level above and below the kyphotic vertebrae that are included in the posterior fusion..

42. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 42 In curves of more than 60 degrees,- anterior and posterior spinal fusions at least one level above nd one level below the kyphosis are indicated. This halts the progression of the kyphotic deformity, but because the ante- rior physes are ablated there is no possibility of correction with growth.

43. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 43 if the kyphosis is less than 50 to 55 degrees posterior fusion alone may be successful in older patients with type I Deformity >55 degrees, -----anterior and posterior fusion produces more reliable results. . Use of skeletal traction (halo-pelvic, halo-femoral, or halo-gravity ) to correct the deformity is tempting but is not recommended because there is a risk of paraplegia Traction pulls the spinal cord against the apex of the rigid kyphosis , which can lead to neurological compromise in a patient with a rigid gibbus deformity.

44. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 44 Late treatment of a severe congenital kyphotic deformity that is accompanied by spinal cord compression laminectomy has no role If there is an associated scoliosis, the anterior approach for decompression may need to be on the concavity of the scolio - sis to allow the spinal cord to move both forward and into the midline after decompression. After adequate decompres - sion , the involved vertebrae are fused with an anterior strut graft. Posterior fusion, with or without posterior stabilizing instrumentaion Anterolateral exposure of spine and partial removal of apex of kyphosis . B, Posterior cortex is removed, allowing decompression of spinal cord. C, Cord is decompressed and strut grafts are in place.

45. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 45   TREATMENT OF TYPE II DEFORMITY If a type II kyphosis is mild (<50 degrees) and detected early, posterior fusion using compression instrumentation. All the involved vertebrae plus one vertebra above and one vertebra below the congenital kyphosis should be included . Because the kyphosis is rounded and affects several seg - ments in type II deformity, instead of being sharply angular as in type I, compression instrumentation can be safely used. 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

46. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 46   COMPLICATIONS OF OPERATIVE TREATMENT pseudarthrosis , progression of kyphosis , and paralysis. COMPLICATIONS can be minimized by 1.performing anterior and posterior fusions for deformities of more than 50 degrees. 2.The posterior fusion should extend from one level above to one level below the involved vertebra. Paralysis can be lessened by not attempting to maximally correct the deformity with instrumentation. Instrumentation should be used more for stabilization of rigid deformities instead of correction. Another long-term problem,, is low back pain caused by increased lumbar lordosis

47. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 47 PROGRESSIVE ANTERIOR VERTEBRAL FUSION Progressive anterior vertebral fusion is an uncommon cause of kyphosis in children d/d with type II congenital kyphosis if it is discovered late. However, it is distinguishable from type II congenital kyphosis in that the disc spaces and vertebral bodies are normal at birth and later become anteriorly fused. Associated anomalies, including hearing defects, tibial agen-esis , foot deformities, Klippel-Feil syndrome, Ito syndrome, pulmonary artery stenosis , and hemisacralization of L5,

48. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 48 INFANTILE LUMBAR HYPOPLASIA thoracolumbar kyphosis MAY resolve spontaneously with growth

49. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 49 UNUSUAL CAUSES OF KYPHOSIS 1.POSTLAMINECTOMY SPINAL DEFORMITY Laminectomies most often are done in children for the diag - nosis and treatment of spinal cord tumors, although they also may be needed in other conditions, such as neurofibromato - sis and syringomyelia . in children. The incidence of spinal deformity ranged from 33% to 100%. Kyphosis is the most common deformity that occurs after multiple-level laminectomies . higher the level of the laminectomy , the greater the likelihood of spinal deformity or instability.

50. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 50 TREATMENT best to prevent When laminectomy is necessary, the facet joints should be preserved whenever possible. Localized fusion at the time of facetectomy or laminectomy may help prevent progression of the deformity, laminoplasty to expose the spinal cord may lessen the chance of progressive deformity. This approach involves suturing the laminae back into place after removal or removing just one side of the laminae and allowing them to hinge open like a book to expose the spinal cord and then suturing that side of the lamina back in place

51. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 51 ACHONDROPLASIA most common of the bony dysplasias . The most frequent spinal deformity - thoracolumbar kyphosis,at birth As muscle tone develops and walking begins, the kyphotic deformity usually resolves, although persistent in some

52. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 52 This kyphosis is poorly tolerated because of the decreased size of the spinal canal related to a marked decrease in the interpedicular distance in the lower lumbar region and to shortened pedicles, which cause a reduction in the anteropos - terior dimensions of the spinal canal.. TO PREVENT PROGRESSION Early bracing to prevent progression and correction of any associated hip flexion contractures to prevent hyperlordosis below the kyphosis are recommended.. prevent unsupported sitting keep young children from sitting up more than 60 degrees even with support. If the kyphosis developed and became greater than 30 degrees, TLSO bracing was begun and con- tinued until the child was walking independently and there was evidence of improvement in vertebral body wedging and kyphosis .

53. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 53 progresses despite conservative treatment, operative stabilization is indicated. The indications 1.documented progression of a kyphotic deformity, 2.kyphosis of more than 40 degrees in a child older than 5 or 6 years, and 3. neurological deficits relating to the spinal deformity. Neurological deficits can occur due to direct result of the kyphotic deformity lumbar stenosis . narrowing of the foramen magnum and basilar impression.

54. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 54 MUCOPOLYSACCHARIDOSES Morquio , Hurler, and Maroteaux-Lamy syndromes are the types most commonly associated with structural changes of the spine. kyphosis , usually in the thoracolumbar junction . 1.The vertebral bodies of these patients are deficient anteriorly and are flattened, beaked, or notched. 2.The intervertebral discs are thick and bulging, often larger than the bodies. 3.The kyphosis is flexible in childhood but with progression becomes increasingly rigid

55. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 55 Hurler syndrome rapidly progressive, and affected children usually die before the age of 10 years Morquio syndrome frequent occurrence of atlantoaxial instabil-ity – c1 c 2 fusion developing gibbus during childhood be treated with an appropriate spinal orthosis to prevent neuro -logical deficits. Surgical treatment anterior discectomy and anterior instrumentation to correct the tho - racolumbar gibbus in these patients. The advantages opportunity for anterior decompression by excision of the bulging disc before correction of the kyphosis ; period

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57. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 57 Spinal deformity in Morquio syndrome. A, Hook-shaped bodies in young child. B, Further anterior ossification in older child. C, Flattened, rectangular vertebral bodies in adult.

58. 9/20/2013 KAKATIYA MEDICAL COLLEGE / MGM HOSPITAL WARANGAL 58 REFERENCE ‘CAMPBELLS 12 EDITION ; ;

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