Scoliosis

SCOLIOSIS ppt.

1. SCOLIOSIS MODERATOR – Dr.Nandish PRESENTER – Dr.Venkatesh Singh

2. DEFINITION “Scoliosis” - Greek word meaning “crooked.” Scoliosis is defined as lateral deviation of the normal vertical line of the spine , which when measured on a radiograph , is greater than 10 degrees , with associated rotation of vertebrae Patients with curves less than 10 degrees are considered to have spinal asymmetry 12:40 AM

3. The lateral curvature of the spine is associated with rotation of the vertebrae within the curve- a three-dimensional deformity occurs in three planes: (1) lateral intervertebral tilting in the frontal plane (2) a rotatory component in the axial plane (3) intervertebral extension in the sagittal plane leading to lordosis of the scoliotic segment

4. The c o mm o n right ( dex tr o ) th orac i c curv e, ( m e asu ring 1 ° ) - co n sider e d p h ysiol o gi c - t o a c c o mm o d a te th e siz e a n d po si t i o n o f th e h e art, lung , a n d a o rta o r t o b e r elated t o ha nd ed n e s s. 7 times more prevalent in females 80% of scoliosis origin unknown

5. Lateral displacement Angular displacement

6. Classification Stru c tura l ( rad i o g r aph i c a l l y Co bb angle o f 25 ° o r more o n ipsil a tera l s i d e-b e ndi n g ra d i o g r a ph i c v i e w s) N o n -st r uctur al - compensatory and postural

7. Based on aetiology : Idiopathic Congenital Neuromuscular Syndromic AG E- B A SE D: (id i opa t hi c ) infant i l e ( b i rth and 3 ye a r s ) ju v e ni l e ( 3 and 10 y ears of a ge ) ado l e s c e nt (1 - ske l et a l mat u rity ) MC

8. NON STRUCTURAL A reversible lateral curve of the spine that tends to be positional or dynamic in nature. No structural or rotational changes in the alignment of the vertebrae. Disappears when the patient is supine or prone or sitting . 12:44 AM

9. Correction of the lateral curve is possible by : -Forward or side bending -Positional changes and alignment of the pelvis or spine. -Muscle contraction -By correction of a leg-length discrepancy

10. Etiology of Nonstructural scoliosis- Leg length discrepancy : (structural or functional) Measurable difference because of a dislocated hip, asymmetric leg or foot postures. Habitual asymmetric posture : Sitting with weight shifted onto one hip or standing with weight primarily supported on one leg Muscle guarding or spasm from a painful stimuli in the back or neck

11. CONGENITAL SCOLIOSIS Congenital scoliosis is a progressive three-dimensional deformity of the spine caused by congenital anomalies of the vertebrae that result in an imbalance of the longitudinal growth of the spine. the familial incidence = 1% to 5% more common in girls ( 3 : 2)

12. DEVELOPMENT OF SPINE Paraxial mesoderm on either side of the notochord -form somites ( Somitogenesis ) Each somite subdivides further into ventral sclerotome and dorsolateral dermomyotome . 4 th week of development- cells from the sclerotome on each side of the body migrate ventrally and surround the notochord Each vertebra is formed by sclerotome cells from two somite levels . The ventral part of each vertebra forms the body around the notochord, and the dorsal part forms costal processes laterally and the vertebra arch dorsally.

13. 6th week of development- mesenchymal cells fill the space between two vertebral bodies to contribute to formation of the intervertebral structures . This stage is called Segmentation stage .

14. Anomalies occur in 30% to 60% MC -the spinal cord and the genitourinary tract. Intraspinal anomalies include - tethered cord, diastematomyelia , and syringomyelia . The most common genitourinary defects are renal agenesis, ectopic kidney, duplication, and reflux. VACTERL association : V ertebral defects (V), A nal atresia (A), C ardiac defect (C), T racheo e sophageal fistula (TE), R adial limb reduction, and R enal defects (R) and L imb defect (L) in Klippel-Feil syndrome, Marfan syndrome, Ehlers- Danlos syndrome, Charcot-Marie-Tooth disease.

15. HUETER-VOLKMAN PRINCIPLE Hueter - Volkmannn Law :bone growth in the period of skeletal immaturity is retarded by mechanical compression on the growth plate and accelerated by growth plate tension

16. the rotation of vertebral bodies in the axial plane causes discrepant axial loading between the ventrally and dorsally located portions of the involved vertebrae ventra l l y l oc a te d par t o f th e vertebral co l u m n become s th e conc a ve sid e th e dorsall y located par t become s th e conve x sid e o f a latera l cu r ve

17. NEUROMUSCULAR SCOLIOSIS The second most common form of scoliosis and is associated with disorders of the nerve or muscular systems, such as: a) Neuropathic - 1)Lower motor neuron( e,g.poliomyelitis ) 2)Upper motor neuron( e,g . cerebral palsy) b) Myopathi c - 1)Progressive( e,g . muscular dystrophy) 2)Static( e,g . Amyotonia congenita ) 3)others( e,g.Friedreich’s ataxia, unilateral amelia )

18.  These cause muscles to become weak, spastic or paralyzed — and unable to support the spine, resulting in spinal curvatures. Treatment will depend on child's age and underlying condition, as well as the type and severity of the spinal curve.

19. IDIOPATHIC SCOLIOSIS Idiopathic scoliosis is the most common type of scoliosis. defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine in the absence of any known cause Idiopathic scoliosis is divided into three categories based on chronologic age: - infantile (birth to 2 years+ 11 months) - juvenile (3 years to 9 years+11 months), - adolescent (10 years to 17 years+11 months) 12:44 AM

20. INFANTILE IDIOPATHIC SCOLIOSIS Co m m o n in E u r o p e M a l e p red om ina n ce L ef t t ho r a c i c curv e p a tter n i s m o st co mm o n T w o t yp e s ha ve b e e n i d e nti f i e d : a r e s o l v in g type ( 85 % ) a n d a p r o gres si v e type ( 15 % )

21. curves that can progress can be obtained from the rib-vertebral angle difference (RVAD) and “ phase of the rib head .” If the head and neck of the convex rib of the vertebral body at the apex of the curve does not overlap the vertebral body, it is termed phase I if it does overlap , it is termed phase II. Curves with RVAD greater than 20 degrees or phase II angles are very likely to progress 12:44 AM

22. JUVENILE SCOLIOSIS 1 2 % – 1 6% o f a ll p a t i e n t s w i t h id i o p a t h i c s c o li o s i s I n c r e a s i n g f e m a l e p r e do m in a n c e M o s t c o m m o n c ur ve p a t t e r n s a r e rig h t t h o r a c i c A p p r o x i m a te ly 7 % o f curv es p r o g r ess

23. ADOLESCENT SCOLIOSIS mo st c o mmo n t y p e o f s c o l io s i s i n c hild r e n A f e ma l e p r e do mi nan c e T ho r a c i c cu r v e p a t t er n s a r e gener ally c on ve x to th e r i g h t I d i o pa t h i c s c o l i o s i s i n a d o le s c e nce i s no t t y pi ca l l y a s s o c iat e d wi t h s eve re p a i n

24. CLINICAL FEATURES 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) )

25. Raised shoulders(thoracic curves-convex side) (Lumbar curves – concave side) Scapula – rotated outwards and forwards with elevation on convex side Increased flank creases – concave side Higher ASIS PSIS – concave side 12:44 AM

26. Physiol o gical Effects of Scoliosis Mid-back pain lower back pain, neck pain, headaches, premature disc and joint degeneration Decreased pulmonary function

27. MANAGEMENT

28. Patient history Age at onset Evidence of maturation Back pain complete neurological history Family history  Self-perception

29. Physical examination Height measurement Gait check Foot shape Skin inspection Assessment of pubertal development Neurological examination ( including motor, sensory and reflex tests ) Symmetry of shoulders and iliac crest 12:54 AM

30. Assessment of scoliosis th e fo u r b a si c spina l par a meters e v a l uate d in sco l iosis are curvatur e rotati o n fle x ibility ske l et a l maturat io n

31. SCOLIOMETRY The Sco l io m eter is p lac e d on the back and m e a s u res th e apex (th e h i g h est p oint) of th e u p per back cur v e .

32. ` Plumb line - On posterior aspect, line drawn from occiput should normally align with gluteal cleft

33. ADAM’S F O R W ARD BEND TEST

34. 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

35. Non structural curve- Curve is flexible and corrects by bending towards convex side

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. 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

38. THORACIC curve – STRUCTURAL LUMBAR curve – COMPENSATORY 12:45 AM

39. The end vertebrae (E) - are most tilted Apical vertebra(A )- is the central vertebra within a curve. It is typically the least tilted , most rotated , and most horizontally displaced vertebra within a curve A neutral vertebra (N) - one that is not rotated a stable vertebra (S)- is one that is bisected or nearly bisected by the CSVL (dotted line)

40. CURVATUR E M E ASUREMENT C O B B - L I PPM A N N : most ac c ept e d AP radio g raph entir e sp i n e a l ine is draw n along th e super i o r bord er o f the c e phala d en d verte b ra and in f eri o r s urfa c e o f the ca u da d en d vert e b ra Perpen d i c ula r line s are ere c te d fr o m eac h en d plate line , and th e v erti c al (not horiz o nt a l ) a n gl e forme d by thei r intersec ti o n is measured 12:45 AM

41. Double curve One vertebra is upper end vertebra for lower curve and lower end vertebra for upper curve (transitional vertebra). Only one line drawn on this vertebra.

42. King-Moe classification Published in 1983 t h o r a c i c c u r ve p att er n s f i ve c u r ve ty p e s as a g ui d e t o s u rg i c al tre a t me nt T h e King c lassi f i c a ti o n d o e s n o t a d d re s s l u m b a r c u r v es, t h orac o lu m ba r c u r v e s, or t r ipl e m aj or c u r v e s. I t d o e s n o t e v aluat e sagitta l pl a n e ali gn m e nt .

43. T y p e 1 : S - sh a p e d c u r v e i n w h i c h b ot h t he t h o r a c i c a nd l u m b a r c u r v e s c r o ss t he m i d l i n e . Bot h c ur v e s a re s t r u c t u r a l , a nd t h e l u m b a r c u r v e m a y b e la r g e r or l e s s fl e xi b l e t h a n t h e t h o r a c i c c u r v e T y p e 2 : S - sh a p e d c u r v e i n w h i c h t h e t h o r a c i c c u r v e i s la rger o r l e ss fl e xi b l e t h a n t h e l u m b a r c ur v e ( a l so c a l l e d a “ fal s e ” d o ub l e m a jo r c u r v e ) T y p e 3 : S i n g l e t h or a c i c c u r v e w i t h o u t a s t r u c t u r a l l u m b a r c u r v e T y p e 4 : L o n g t h o r a ci c c ur v e i n w h ic h L5 i s c e n t e r ed ov er t h e s a c r u m a nd L4 i s t i lt e d i n t o t h e t h o r a c i c c u r v e T y p e 5 : D o u b l e t h or a c i c c ur v e w i t h T1 ti l t e d i n t o t h e c o n v e xi t y o f t h e upp e r c u r v e

44. two-dimensional classification system, published in 2001 included the sagittal plane as well PT,MT,TL/L curves are measured using the Cobb technique. The larger of the latter two is considered the major curve. Lesser curves are termed minor and are considered structural : if they remain at least 25 on side-bending films or Hyperkyphosis in the PT region (T2–T5>20) or TL(T10–L2>20) ,regardless of their sidebending measurement.

45. PT curves are always minor 42 curve patterns The type 1 (single thoracic) curve is the most common The general principle : major curve and structural minor curves should be fused nonstructural minor curves may be allowed to correct spontaneously following fusion of the structural curves. 12:45 AM

46. LIPPMAN - COBB’S classification GROUP ANGLE OF CURVATURE I <20 II 21-30 III 31-50 IV 51-75 V 75-100 VI 101-125 VII >125

47. Cobbs pitfall diurn a l variation o f 5 ° difficu l t t o p ositio n th e pati e nt intraobserver va r iation b y 5 ° – 1 ° in C o b b angle

48. Cen t e r o f eac h end vertebra a nd th e apical segm e nt are join e d, and t hei r intersecting acute angle is measured. Ri s se r - Ferguso n systems

49. S C OL I O TI C IN D EX 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. Lines are then drawn from the centre of each vertebral body perpendicular to the vertical spinal line ( aa ', bb', … gg ').

50. 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

51. D E G RE E O F R O T A T I O N 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. 12:45 AM

52. NASH AND MOE

53. COBB SPINOUS-PROCESS METHOD Migration towards the convexity of the curve marks the degree of rotation.

54. DETE R MINING M A TUR A TION Secondary sex characteristics Excursion of iliac apophysis ( Risser's staging) Ossification of the vertebral ring apophysis . Triradiate cartilage Bone age

55. RISSER’S STAGING fir s t appears l a tera l l y near th e A SIS and progresses medially towar d completio n at th e P SIS (cappin g ) Boys - 16yrs ; Girl s 1 4yrs grade 4 in F and grad e 5 in M us u a l l y signal s th e end o f cu r ve progressi on

56. Vertebral Ring Epiphyses closely parallels the maturation of spinal growth. most accurate indicator of completed spinal growth strong inhibiting factor to future scoliotic progression.

57. TRIRADIATE CARTILAGE Y- shaped epiphyseal plate that occurs at the junction where the ischium , ilium and pubis meet in the skeletally immature skeleton Closure or fusion - 15 - 16 years in males 13 - 14 years in females beginning at the acetabulum and finishing at the greater sciatic notch between ilium and ischium .

58. Assessment of Vertebral Alignment and Balance The plumb line : vertical line drawn downward from the center of the C7 vertebral body , parallel to the lateral edges of the radiograph CS VL : v e rtical l i ne th a t is drawn perp endicu l ar t o a n im a gin a ry t angential l i ne dra w n ac r os s th e to p of th e i l i a c c rests on ra d i o g r a phs . It b ise c t s the sac r um .

59. COR O NA L BALA N C E eval u at e d b y meas u ring th e distance b e twe e n the C S VL and t h e plu m b line gr e at e r tha n 2 c m is a b normal SAG I T TAL BALANCE eval u at e d b y meas u ring th e distance b e twe e n the p o st e rosuperior asp e c t of th e S 1 verte b ral bod y and th e plum b line

60. T he Probability of Progression curve progression parallels spinal growth. progresses only during growth ceases when skeletal maturity is reached (final curvature is not severe) > 50 degree -more Morbidity mortality (cardiopulmonary complications) 12:45 AM

61. less than 30°: tends not to progress After the cessation of spinal growth, only curves with a Cobb angle greater than 30° -monitored for progression Lumbar and thoracolumbar curves are more likely to progress than thoracic curves because they lack the inherent stability provided by the rib cage.

62. Congenital scoliosis progresses in 75% of cases Idiopathic Infantile rarely progress Idiopathic Juvenile progress 75-80 % Idiopathic Adolescent progress only 5% The factors that have the greatest effect on scoliosis are spinal growth velocity and magnitude of the curve at initial presentation

63. TREATMENT Dr.Lewis Sayre

64. Infantile idiopathic scoliosis Resolving curves : -observed -serial physical examinations and radiographic monitoring. -Sleeping in the prone position- recommended Progressive curves – treated with serial casting followed by orthotic treatment

65. Tre a tment opti o ns fo r pro g re s sive cu r ves Serial casting + bracing+ later fusion Preoperative traction + later fusion Growing rod or vertical expandable prosthetic titanium rib( VEPTR ) instrumentation without fusion

66. Best results if casting started < 20 months of age and <60 degree curves Cast change every 2-4 months Once corrected to < 10degrees -use custom moulded brace

67. Operative tre a tment Indicated if curve is severe or increases despite use of an orthosis /casting Principle of surgery - surgery should not only stop progression of the curve but also allow continued growth and development of the thorax and lungs Fusionless instrumentation techniques are preferred(VEPTR)

68. Posterior spinal instrumentation and fusion are not recommended due to: re str i c t i o n o f t h orac i c ca g e and lun g d e v e l o p m e n t th e r is k o f cr a nk s h a f t ph e n o me n o n ( per si s t e n t a n t e r i o r sp i n a l gr o w t h i n t h e p r e s en c e o f a p o s t er io r f u sio n , l e a d i n g t o re c u r r e n t a nd i n c r e a s i n g s p i n a l d e fo r m i t y ) . Growing rods may be used to control curve progression and still allow for growth of the spine . Requires surgery every 6 months to lengthen the rods The use of magnetically controlled growing rods , such as the MAGEC

69. Magnetically controlled growing rod magnetic technology with adjustable growing rods and an external remote controller spinal bracing and distraction system avoids a return to surgery every 6 months

70. 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 and to pivot on the posterior fusion causing loss of correction, increase in vertebral rotation, and recurrence of the rib hump Combined fusion necessary- to prevent crankshaft phenomenon

71. Treatment of juvenile idiopathic scoliosis Orthotic treatment is initiated for curves in the 25° to 50° range. Surgical treatment is considered when curve magnitude exceeds 50° convex disc stapling - an option for fusionless correction of scoliosis

72. Sur g ical o p tions principle of surgery – posterior instrumentation that is sequencially lengthened to allow longitudinal growth while still attempting to control progressive spinal deformity. Growing rod-surgery is required every 6 months to lengthen the construct Dual growing rod- effective in controlling severe spinal deformities and allowing spinal growth

73. Guided growth and physeal stapling – Princi p le of s u rgery - i n tererte b ral stapl i ng is us e d to pr o duce a tet h eri n g ef f ect on t h e co n vex si d e of t h e spi n e. T h i s will a l low for cont inued growt h on t h e concave side of th e spi n e def ormity and gradua l correction of t h e deformity with growth

74. Ad o l e s cen t i d i o path i c s c o l iosi s Nonoperative treatment- 1 .observation- young patient with mild curve <20 2 .orthotic treatment- progression of curve beyond 25 Curve of 30-40 in skeletally immature SRS optimal inclusion criteria for bracing: Age 10yrs or older Risser grade 0-2 Primary curve angle 25-40 No prior treatment 3 .Underarm cast

75. O r th os i s ( B r a c i ng) to prevent curve progression Successful brace treatment is the initial correction achieved by 50% or more upon initiation of bracing braces are applied when a curve is progressing and is between 20 deg and 40 deg . rarely does a brace work after a curve is 40 deg or greater

76. C o n t ra indi c a t i o ns o f b rac e t rea t me n t : S k e l e t a l l y mat u r e p a t ie n t s C u rve s gr eat e r t ha n 4 ° T h o r ac i c l or d o s i s (b r ac i ng p o t en t i a te s ca r d i o p u l m o na r y re st r i ct i o n) P at ie n t s u n a b l e t o c o pe e m o t i o n ally wi t h t re at m e nt

77. Typ e o f B r a c es C TL S O ( M i lw a u k ee b r a ce ) . U s e d l ess c o mm o n l y du e t o i t s c os m et i c a p p e a r anc e . H o w e ver , fo r c u rv e s w i t h an a pe x a bo v e T 8 , i t re m a in s m o s t e f f ic a c i ous TL S O ( e .g . B os t on b r a ce ) . T he s e l o wer - p r of il e o r th os e s a re b e tte r a c c e p te d b y p a t i e n t s a n d a r e i n dic a te d f o r c u r v e s w i t h an a pe x a t T 8 o r be l o w

78. B e n din g bra c e ( e .g . C h a r l e s t on b r a c e ) . h o ld s t h e p a t i e nt i s a n a c u t e l y b e nt p o s i t i on i n a di re ct i on o p p o s i t e t o th e c ur v e a pe x . I t i s w o r n only d u r in g s le e p . F l e xibl e b r a c e (e . g . Spi n e C o r bra c e )

79. HALO-TRACTION DEVICE: A spinal skeletal traction and fixation device attached to the skull and is connected to a plaster body cast by an adjustable steel frame. especially valuable in scoliosis when cardiopulmonary insufficiency contraindicates the use of corrective cast. used with distal traction through pins inserted in the distal femurs or proximal tibias , permitting the use of respiratory aids and surgery while in traction.

80. Pr o g n o si s- F a c to r s : C u rv e m a g ni t u de : m o r e a n g u l a t i on & r o t a t i o n , p r o gre ss m o re ( > 2  ) A g e : y o u n ger , p r o gre s s m o r e ( < 12 y o ) R i ss e r ’ s s c o r e : s c o r e - 1 , p r o gre ss m o r e C u rv e le n g t h : s h o r t e r cu rv e s, p r o gre ss m o r e L o cati on : h ig her c u r ve s, p r o gre s s m o r e F lexi b il ity : st iff e r cu r v e s, p ro gr e s s m o re

81. Oper a t i v e / S u r g ery Objective : obtain a solid fusion and to have the top and the bottom of the fusion balanced within the stable zone. Indications for surgery : <30 failed conservative treatment 30 - 45, with progression >30 with cosmetically unaccepted in skeletal maturity Increasing curve in growing child asymmetry of trunk in adolescent Pain uncontrolled by nonoperative treatment Thoracic lordosis Significant cosmetic deformity

82. Goals : Halting progression Achieve correction Achieve spinal balance Objectives : Reduce rotational deformity & lateral deviation Athrodese the primary curve

83. pulmonary function tests preoperatively on all patients. cardiopulmonary compromise present - posterior fusion is preferred over an anterior approach to avoid pulmonary insult of a thoracotomy clinical appearance of shoulder height and symmetry is important in the selection of fusion levels.

84. Typ e s : P o s te r i o r app r oa c h A n ter i o r app r o a c h C o m bi n e d post e r i o r & a nt e r i o r ap p r o a c h Vi d e o- a ssis t e d Tho r a c os c opi c Su r ge r y (V A TS)

85. Posterior surgeries : -Posterior spinal instrumentation- pedicle hook implantation sublaminar wires and cables Pedicle fixation- lumbar pedicle screw -thoracic pedicle screw - Facet fusion- Moe/Hall technique

86. Ha r ri n g t on rod Instr u m e nt ati o n

87. Luque trolley: uses wires to facilitate spine growth the wires slide along contoured rods. Shilla procedure: spinal fusion at the most severe portion of the scoliotic curve; termed the apex. anchor points at the top and bottom of the curve. The screws at the ends of the spine are specially designed to allow movement and growth along the rod

88. SHILLA LUQUE

89. Anterior surgeries Disc excision Anterior thoracoplasty Video assisted thoracoscopy ( VAT ) = screw insertion = discectomy = CD horizon eclipse spinal insrumentation C -A r m F l u o r o s c op i c V i e w o f V er t e b r a l S cre w In s er t i o n

90. Vertebral Body Tethering: Fusionless Pediatric Scoliosis Correction

91. Segmental PEDICLE SCREW construct

92. CD HORIZON® Legacy™ Spinal System by Dr. Lenke The Legacy System is a complete and comprehensive system of a variety of implantable devices, including rods, hooks, screws, and other instrumentation Comprehensive three-dimensional (3D) correction of the spinal deformity.

93. CASES WITH XRAYS 1

94. Adolescent Idiopathic scoliosis with progression of the curve AIS with Lenke Type 3B- main curve (T6-T11) 72 degrees. Failure to control curve inspite of bracing Patient not satisfied with the body perception

95. 2 Pre op

96. Post op

97. THANK YOU

98. REFERENCES : Rothman- The spine Tachdjian Pediatric Orthopaedics Gopalan’s evidence based orthopaedcis principles Campbell’s operative orthopaedics Rockwood and Green’s fractures in adults www.srs.org ( Spine Research Society)

99. Posterior segmental spinal instrumentation and fusion are indicated in type 1 curves with a normal or hyperkyphotic sagittal profile and in patients with diminished pulmonary function Instrumented posterior spinal fusion from the neutral vertebra above to the stable vertebra below (or stable minus one or two levels as defined below) is the traditional treatment type 1 MT curves can be fused to the ‘‘stable minus one’’ vertebra.

100. Anterior spinal fusion may be selected in type 1 curves, particularly when there is hypokyphosis or a ‘‘C’’ lumbar modifier . Anterior fusion may be preferred in a patient who is skeletally immature to minimize the risk for crankshaft phenomenon from subsequent growth. Because anterior fusion tends to increase kyphosis , whereas posterior fusion tends to decrease it , anterior fusion may not be suitable in patients with preoperative high normal or hyperkyphosis use of segmental thoracic pedicle screw fixation increased instrumented curve correction, improved spontaneous lumbar compensatory curve correction, and improved thoracic torsion and rotation

101. With hook constructs, it has been recommended that the distal level be the “ stable” vertebra , the one that is intersected or bisected by the center sacral line the appropriate level to fix proximally is determined by the sagittal plane as well. In the sagittal plane, the top and the bottom of the fusion should be transitional, in an area of relative lordosis Established teaching was that posterior fusion should stop two levels above and one level below the transitional segments Those levels can at times be shortened if fixation is achieved at every level with hooks or pedicle screws and if the “saving of levels” is compatible with the sagittal plane

102. LIV should achieve horizontalization , centralization, and stabilization

103. Prox fusion – acc to shoulders Higher shoulder fusion level prox Left T2 Level T3/4 Right T4/5