Scoliosis

scoliosis

1. HOD:PROF.DR.K.PRAKASAM M.S.Ortho,D.Ortho,DSC (HON) MODERATOR:DR.A.E.MANOHARAN PRESENTOR:DR.THOUSEEF.A.MAJEED Scoliosis

2. INTRODUCTION “Scoliosis” - Greek word meaning “crooked.” It is a lateral curvature of the spine in upright position. The Scoliosis Research Society has defined scoliosis as a lateral curvature of the spine greater than 10 degrees as measured using the Cobb method on a standing radiograph .

3. Triplanar deformity of lordosis , rotation & lateral wedging of vertebrae. It produces body disfigurement. When deformity is extreme it compresses viscera and reduces life expectancy of the patient.

4. Incidence of Scoliosis Develops between ages 8 to 15 (growth spurt) 7 times more prevalent in females 80% of scoliosis origin unknown

5. “Normal” alignment Spinous processes all line up in a straight line over the sacrum Scoliosis is a combination of Angular displacement Lateral displacement Spinal Biomechanics

6. Lateral displacement Angular displacement

7. Classification I. Non structural Scoliosis (Postural) II. Transient Structural Scoliosis III. Structural Scoliosis

8. I. Non structural Scoliosis Postural Scoliosis Compensatory Scoliosis Transient Structural Scoliosis Sciatic Scoliosis Hysterical Scoliosis Inflamatory Scoliosis

9. III. Structural Scoliosis Idiopathic Scoliosis Old Classification Infantile Onset < 3 yrs Age Juvenile Onset 3-10 yrs Age Adolescent Onset > 10 yrs Age New Classification Early onset Onset < 8 yrs Age Late onset Onset > 8 yrs Age

10. NEUROMUSCULAR DISORDER ASSOCIATED SCOLIOSIS NEUROPATHIC Poliomyelitus Cerebral palsy Syringomyelia MYOPATHIC Muscular dystrophy Unilateral Amelia Friedreich’s ataxia

11. TRAUMATIC SCOLIOSIS Vertebral Extra vertebral eg : Burns eg : Fractures, irradiation Surgery

12. OTHER CAUSES OF SCOLIOSIS Neurofibramatosis Marfan’s syndrome Moroquio’s disease Arthrogryposis multiplex congenita Rheumatoid arthritis Stills disease Scheuermann’s disease Osteogenesis imperfecta Scoliosis assosiated with spinal tumours.

13. Physiological Effects of Scoliosis Mid-back pain lower back pain, neck pain, headaches , premature disc and joint degeneration Decreased pulmonary function

14. Descriptive terms The side towards which the convexity of the curve is directed is designated as Right or Left. The involved location of the curve is described as Cervial Cervico thoracic Thoracic Thoracolumbar & Lumbar

15. Simple curve - Single spinal deviation Compound curve - Displacements in Right & Left direction Primary curve - Curve that develops first Secondary or Compensatory curve - Develops as a balancing response to the primary curve

16. Non structural curve- Curve is flexible and corrects by bending towards convex side Structural curve- Curve is not corrected on bending on convex side ( vertebral and para -vertebral bodies and soft tissues are deformation developed)

17. Major curve - Significant structural changes take place (the one of greatest degrees) Minor curve- Secondary or compensatory curve in the opposite direction above and below the major curve. Usually functional and nonstructural

18. Double major curve : Two balancing curve of equal structural change and magnitude. Thoracic curve is major and the lumbar curve is structural. Because the main thoracic curve is always larger than the thoracolumbar /lumbar curve.

19. Function of curves Strength Flexibility

20. Most commonly used classification Describes 5 specific types of thoracic curves based upon coronal radiographs Recommended specific fusion levels depending upon the curve type. KING CLASSIFICATION

21. Type I - lumbar dominant (10%) - S-shaped curve, Both thoracic and lumbar curves cross midline, Lumbar curve larger or more rigid King classification

22. Type II - thoracic dominant (33%) - S-shaped curve, Both thoracic and lumbar curves cross midline, Thoracic curve larger or more rigid King classification

23. Type III - thoracic (33%) -  Thoracic curve, Lumbar curve does not cross midline King classification

24. Type IV - long thoracic (10%) - Long thoracic curve, L5 over sacrum, L4 tilted into curve King classification

25. Type V - double thoracic (10%) - Double thoracic curve, T1 tilted into upper curve, Upper curve structural King classification

26. INFANTILE IDIOPATHIC SCOLIOSIS Younger than age of 3 years B oys > girls , P rimarily thoracic and convex to the left. One hip is prominent but no ribs to accentuate deformity Associated with Mental deficiency, Congenital dislocation of hip, Congenital heart defects

27. Self-limiting Spontaneously resolve (70% to 90%) Progressive - Compensatory or secondary curves develop, > 37 degrees by C obb Method

28. JUVENILE IDIOPATHIC SCOLIOSIS Uncommon Between the ages of 4 and 10 years Right Thoracic curves 12% - 21% of idiopathic Prognosis is worse Surgical correction may be necessary before puberty

29. Commonest type Age 10- 16 yrs Primary thoracic curve usually convex to right Lumbar curves to the left Intermediate ( thoracolumbar ) & combined (double primary) curves also occur Curves under 20 degree either spontaneously or remain unchanged ADOLESCENT IDIOPATHIC SCOLIOSIS

30. ADOLESCENT IDIOPATHIC SCOLIOSIS Proposed etiological factors, genetic factors, neurological disorders, ( 3) hormonal and metabolic dysfunction, ( 4) skeletal growth, ( 5) biomechanical factors, and ( 6) environmental and lifestyle factors.

31. Once starts to progress, it goes on throughout growth period Reliable predictors of progression Very young age Marked curvature Incomplete Risser sign at presentation ADOLESCENT IDIOPATHIC SCOLIOSIS

32. Problems in adult life Back pain, Pulmonary dysfunction , Psychosocial effects, Mortality

33. Slightly more in females More common in right Features midway between adolescent thoracic & lumbar THORACOLUMBAR

34. Common in females 80% convex to left One hip prominent Not noticed early Backache in adult life LUMBAR SCOLIOSIS

35. 2 primary curves, one in each direction Radiologically severe Clinically less noticable Because always well balanced COMBINED SCOLIOSIS

36. Structural scoliosis Non correctable deformity of affected spinal segment. Vertebral rotation is an essential component. Spinous process swing round towards the concavity of the curve. Transverse processes on the convexity rotates posteriorly .

37. In thoracic region the rib on the convex side stand out predominantly & produces rib hump. Initially deformity is corrected. When deformity is fully established the deformity is liable to increase through out the growth period.

38. Types of structural scoliosis Idiopathic scoliosis (no obvious cause). Congenital or Osteopathic.(bony abnormality). Neuropathic Myopathic ( Associated with muscle dystrophies)

39. Congenital or Osteopathic Due to defect in segmentation or defect in the formation including - Hemivertebra - Block vertebra - Wedged vertebra Curves progress rapidly during pre- adolescent growth period

40. CONGENITAL SCOLIOSIS

41. Curve is long, convex towards the side with weaker muscles ( spinal, abdominal or intercostal ) & at first mobile Loss of stability & balance which makes sitting difficult in severe cases Loss of sensibility causes pressure ulceration B.PARALYTIC SCOLIOSIS

42. Deformity is usually the presenting symptom Pain is rare complaint Rib hump or abnormal para spinal muscular prominence indicates spinal rotation Rib hump leads to asymmetry of trunk called angle trunk rotation (ATR) . CLINICAL FEATURES

43. Trunk should be exposed completely & examined in front , back & side Trunk alignment Symmetry of shoulder girdles Scapula & ribcage observed for asymmetry Spinous process palpated to determine their alignment CLINICAL EVALUATION

44. CLINICAL EVALUATION Plumb line - On posterior aspect, line drawn from occiput should normally align with gluteal cleft

45. SCOLIOMETRY The patient bends over, arms dangling and palms pressed together, until a curve is observed in the back. The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve . Bunnell Scoliometer

46. ADAM’S FORWARD BEND TEST Patient is asked to lean forward with feet together and bend 90 degrees at the waist. The examiner can easily view the angle & any asymmetry of the trunk or any abnormal spinal curvatures.

47. To determine the severity of the curve X-ray Antero Posterior, Lateral & Oblique view of spine Right & left bending view – determine the degree of flexibility of spine & to see how much curve can be passively corrected RADIOLOGY

48. X Ray Standing AP film of whole spine on one film.

49. Lateral flexion AP radiographs provide information on the upper and lower limits of a fixed curve Mobility of the motion segments, as an aid to fusion levels.

50. Radiographs are assessed for Spinal column contour Congenital or developmental abnormalities, Degenerative Neoplastic abnormalities

51. CURVE MEASUREMENTS COBBS METHOD RIB ANGLE OF MEHTA SCOLIOTIC INDEX RISSER-FERGUSON METHOD

52. End-vertebrae -maximum rotated vertebra ( most tilted vertebrae ) Apical vertebra -Vertebra at the centre of the curve.

53. Line drawn at end plate of upper end vertebra Another line at lower border of lower end vertebra Perpenidular lines are drawn from above two lines Angle formed between them measured LIPPMAN-COBB METHOD

54. D ouble curve O ne vertebra is upper end vertebra for lower curve and lower end vertebra for upper curve ( transitional vertebra ). Only one line drawn on this vertebra .

55. The difference between the angle formed by a vertical line through the centre of the apical vertebral body on an AP film and the rib on the convex side and the same angle on the concave side. RIB ANGLE OF MEHTA

56. More than 20 or overlap of the head of the rib over the vertebra are associated with a high likelihood of progression.

57. Each vertebra (a–g) is considered an integral part of the curve. A vertical spinal line ( xy ) is first drawn whose endpoints are the centres of the upper and lower end-vertebrae of the curve . SCOLIOTIC INDEX

58. Lines are then drawn from the centre of each vertebral body perpendicular to the vertical spinal line ( aa ', bb', … gg '). The values yielded by these lines represent the linear deviation of each vertebra Sum of vertebral body lines, divided by the length of the vertical line ( xy ) gives the scoliotic index

59. RISSER-FERGUSON METHOD First line originating at the centre of the upper end-vertebra Second line from the center of the lower end-vertebra. Angle formed by the intersection of two lines at the centre of the apical vertebra gives the degree of curvature

60. Rotation – reflects the degree of structural change & resistance to correction of the scoliotic curve 2 methods are used. Moe pedicle method Cobb spinous -process method. DEGREE OF ROTATION

61. When the vertebra rotates, one pedicle moves toward the midline It is the relationship to midline that determines the degree of rotation Other pedicle moves towards the lateral border of vertebral body Displacement of Pedicles

62. Moe pedicle method Divides the vertebra into six equal parts. Normally, the pedicles appear in the outer parts

63. COBB SPINOUS-PROCESS METHOD Vertebra is divided into six equal parts. Normally, the spinous process appears at the center . Its migration to certain points toward the convexity of the curve marks the degree of rotation.

64. Secondary sex characteristics Bone age Excursion of iliac apophysis ( Risser's staging) Ossification of the vertebral ring apophysis . DETERMINING MATURATION

65. Ossification of the vertebral ring apophysis

66. Excursion of iliac apophysis Ossification of iliac crest starts laterally & proceeds medially toward sacrum. Maturation complete, when it reaches Sacroiliac junction

67. Risser's staging Based on iliac crest apophysis ossification Type I – ossification of lateral 25% Type II – lateral 50% Type III – lateral 75% Type IV – lateral 100% Type V – fusion of I lium

68. CT scans are used to provide improved definition of abnormalities of vertebral size, shape or number

69. Magnetic resonance imaging - to evaluate the spinal cord and spinal nerves. Myelography

70. Other Studies Pulmonary function testing for patients with : Curves greater than 60 degrees Respiratory complaints Scoliosis resulting from a neuromuscular cause

71. TREATMENT

72. Aims of treatment To prevent progression of the deformity To correct an existing deformity

73. Nonoperative treatment Observation Orthotics – braces Traction and Casting

74. Non operative Exercises maintain muscle tone but no effect on the curve If curve between 20* & 30* is progressing, bracing done TREATMENT

75. Orthotics Hibbs and Risser – Turnbuckle cast Milwaukee brace ( CTLSO )– 1946 Thoracolumbosacral othosis (TLSO’s) – 1960s

76. Milwaukee brace Pelvic girdle Uprights – one anterior and two posterior. Cervical ring with throat mold and occipital piece Lateral pad – pressure on apical vertebra

77. Thoracolumbosacral othosis (TLSO’s )

78. Contra indictions for orthosis Curve > 40 ° Extreme thoracic kyphosis Mature adolescent ; Risser grade 4 or 5, girls 2 yrs post menarchal High thoracic or cervicothoracic curves

79. Daily application of longitudinal & lateral traction forces mobilize the spine gradually Patient in lying position, head end attached with 10 pounds weight pulls proximally Pelvic girdle & traction straps with 20 to 30 pounds weight pull distally Stretching

80. Halo traction device Spinal skeletal traction & fixation device Halo traction device attached to skull & is connected to a plaster body cast by a steel frame

81. SURGERY Criteria :- Curve more then 40degree Progressive increase in scoliosis Failure to conservative treatment Cardiopulmonary complications .

82. Methods : Herrignton rod :- only fusion of spine vertrebra , no correction of the deformity . Double rod method : - on every single level of vertebra of spine is fixed with screws . Vertebral fusion :- fusion of vertebra where scoliosis develop .

83. A rod is applied posteriorly along the concave side of the curve Movable hooks attached to rod which are engaged in upper & lowermost vertebra to distract the curve Harrington system

84. If curve is flexible, it will passively correct & bone grafts are applied to obtain fusion Disadvantage Does not correct the rotational deformity at the apex of the curve Rib prominence remains unchanged

85. Modification of Harrington system Wires are passed under vertebral lamina at multiple levels & fixed to rod on the concave side of the curve Bending the rod & arranging the mechanism so that wires pull backwards than side wards Rotational deformity is improved ROD & SUBLAMINAR WIRING (LUQUE)

86. Posterior rod system with multiple hooks placed at various levels to produce either distraction or compression With double rods, one can distract on concave & compress on convex side Rotational deformity corrected . COTREL-DUBOUSSET SYSTEM

87. Rigid curves & thora-columbar curves associated with lumbar lordosis corrected from front. Removing the discs throughout the curve & then applying a compression device in the convex of the curve Bone grafts are added to achieve fusion ANTERIOR INSTRUMENTATION (DWYER, ZIELKE)

88. Treated by applying serial elongation- derotation – flexion(EDF) plaster casts Can be applied till 4yrs If deformity deteriorates, surgical correction done Anterior disc excision with use of rod to aid correction INFANTILE IDIOPATHIC SCOLIOSIS

89. Non operative treatment Milwaukee brace from age 1 or 2yrs until 9 or 10yrs when surgery is done Previously, Risser localizer cast was used in children from 1 to 4yrs Indications progressive curve, moderately flexible Non progressive, somewhat flexible but unacceptable CONGENITAL OR OSTEOPATHIC

90. PARALYTIC SCOLIOSIS Conservative---- fitting a suitable sitting support. Surgery---- stabilisation of entire paralysed segment by combined anterior & posterior fusion.

91. CEREBRAL PALSY SCOLIOSIS Most often thoracolumbar curve Pelvic obliquity & hip contracture present INDICATIONS Progressive curve of any degree Normal mortality

92. TREATMENT For severe lumbar & thoracolumbar curves anterior fusion with dwyer instrumentation then after 2 weeks posterior fusion with harrington rods.

93. NEUROFIBROMATOSIS SCOLIOSIS Constitutes about 1% Associated with skin lesions , multiple neurofibroma & bony dystrophy affecting vertebra & ribs Curve is short & sharp Mild cases – conservative Severe cases – combined anterior & posterior fusion.

94. SUMMARY Curves <20’ needs observation. Curves more than 20 treatment. Curves between 20 to 40 degree can be treated by bracing Curves > 40 degree needs surgical correction & fusion.

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