Scoliosis

Scoliosis by Dr. Bipul Borthakur

1. SCOLIOSIS DR. BIPUL BORTHAKUR PROFESSOR, DEPT OF ORTHOPAEDICS, SMCH

2. NORMAL SPINE

3. SCOLIOSIS

4. KYPHOSIS

5. Structural Non-structural

6. Structural scoliosis: Structural curves are fixed, nonflexible, and fail to correct with bending.

7. Non structural scoliosis: Nonstructural curves are not fixed but flexible and readily correct with bending.

8. INTRODUCTION Definition: Lateral curvature of the spine with an element of axial rotation Complex three dimensional deformity:- Frontal: lateral tilting of vertebrae Sagittal: lordosis ( extension) Axial: Rotatory component

9. INTRODUCTION Different types of curves:

10. CLASSIFICATION King Moe classification Lenke classification

11. ETIOPATHOGENESIS According to age Infrantile – up to 4years Juvenile – 4 – 9 years Adolescent – 10 years up to skeletal maturity 85% cases of scoliosis are in adolescent group , among which most cases are idiopathic and most cases are commonly seen in females

12. ETIOPATHOGENESIS Idiopathic Congenital Vertebral – Hemivertebrae , wedge vertebrae, unilateral or bilateral blocks Spina bifida, meningocoele Extraspinal – rib fusion, myositis ossificans progressiva Neuromuscular Cerebral palsy Neurofibromatosis Syringomyelia Myopathies Degenerative Syndromic

13. CLINICAL FEATURES Usually asymptomatic Clinically presents between 10 to 13 years Common in females Usually diagnosed on general physical examination

14. CLINICAL FEATURES On physical examination: Look for facial syndromic features like frontal bossing, hypertelorism , high arched palate Examine back for neuro -cutaneous markers like tuft of hair, nevus, sinus, skin appendage, café-au- lait spots etc

15. CLINICAL FEATURES On examination: In standing position

16. CLINICAL FEATURES On examination: In bending down position Rotation of the curve becomes more prominent Hump in the back One shoulder blade is more prominent than the other

17. CLINICAL FEATURES Neurological examination: Motor strength Sensory Deep tendon reflexes Abdominal reflexes Plantar reflex and Clonus Any abnormal finding is an indication for MRI of spine

18. INVESTIGATIONS Plain radiographs of whole spine AP and lateral view; Bending X-ray Measure the Cobb’s angle - >10deg is scoliosis To assess the behavior of curve CT scan – to study morphology of vertebra and other congenital abnormalities MRI of the whole spine – from posterior fossa of cranium up to conus medullaris To rule out other spinal abnormalities like tethering, spinal tumors, cord status

19. ANALYSIS OF X-RAY To calculate the angles Cobb’s angle Rib angle of Mehta Rib vertebral angle difference Rigger –Ferguson method Determination of age

20. RADIOLOGICAL MEASUREMENTS Cobb’s angle:

21. RADIOLOGICAL MEASUREMENTS Rib angle of Mehta:- Rib vertebral angle – angle between the line drawn perpendicular to the apical vertebral end plate with a line drawn from the midneck to the midhead of the corresponding head

22. RADIOLOGICAL MEASUREMENTS Rib angle of Mehta:- Rib vertebral angle difference – it is the difference between the rib vertebral angle of the convex and concave side of the apical vertebra Initial RVAD <20 deg , progression is unlikely Initial RVAD >20 deg , curves tend to progress

23. RIGGER-FERGUSON METHOD In this method, the degree of scoliotic curvature is determined by the angle formed by the intersection of two lines at the center of apical vertebra, the line originating at the upper end of vertebra, and the other at the center of the lower end vertebra.

24. DESCRIPTION OF CURVE How to describe a scoliotic curve – “PLEAD” P – Pattern (Primary, secondary) L – Location (Thoracic, thoracolumbar, lumbar) E – Etiology (Idiopathic, congenital, paralytic etc.) A – Apex (thoracic, lumbar) D – Direction (right or left)

25. CURVE PROGRESSION RISK FACTORS FOR PROGRESSION OF CURVE Curve magnitude:- Before skeletal maturity :- >25% skeletal maturity will continue to progress. After skeletal maturity :- >50% thoracic curve will progress in 1-2 degree/year. >40% lumbar curve will progress in 1-2 degree/year .

26. CURVE PROGRESSION Peak growth velocity:- It is the best predictor of curve progression. Curve type:- Thoracic curve more likely to progress than lumbar. Double curve more likely to progress than single curve.

27. TREATMENT Observation only Curves less than 20 degrees Examined every 3 to 6 months Conservative treatment Orthotic treatment – Brace application Cobb angle from 20 degree to 50 degree. Only effective for flexible deformity in skeletal immature patient .

28. TREATMENT - braces Milwaukee brace Boston brace Charleston brace

29. TREATMENT - braces Wilmington brace Providence brace

30. TREATMENT Operative treatment:- Posterior spinal fusion Indications- Cobb angle >50 degree. Can be done for all types of idiopathic scoliosis. Gold standard for thoracic and double major curves. Anterior spinal fusion Indications- Best for thoracolumbar and lumbar cases.

31. TREATMENT Operative treatment:- Anterior/Posterior spinal fusion Indications - large curve(>75 degree) or stiff curves and young age .

32. THANK YOU