non-correctable deformity of the affected spinal segment
Kyphotic curves and are described as being convex posterior (concaveanterior). The curves of the spine help to increase the overall strength of the vertebral column and help to maintain balance in the upright position.
According to national scoliosis foundation - 2% to 3% of the population has an abnormal curve to their spine
First locating the endplates of the most angulated inferior and superior vertebrae of the curve. The angle then is determined from the intersection of a line perpendicular to each of the predetermined endplates.9,29 Figure 13 demonstrateshow the Cobb angle is calculated.Lines drawn perpendicular to the end vertebral lines
Worse if associated with hypokyphosis• Death from corpulmonale
A period of preliminary observation may be needed before deciding between conservative and operative treatment4-9 months – examined, x-ray curve measured and checked for progressionExercise no effect on curve, maintain muscle tone
The fit of the brace and curve measurements are checked every 6 months in patients who are still growingeffective at stopping curve progression 70% to 74% of the time in patients who comply with prescribed bracing recommendations.
Scoliosis Dr Nor Hidayah Zainool AbidinInternational Islamic University of Malaysia (UIAM)
OUTLINESNormal vertebral curvatureDefinitionTypes• Non structural/ StructuralClinical featuresImagingTreatment• Conservative/ OperativeSummary
Normal Spine • Primary curves are the natural curves in the spine that we are born with – thoracic and pelvic curves. • Compensatory curves/ secondary curves, develop after birth in response to learned motor skills – Cervical section infant learning to hold his or her head upright and learning to sit unsupported – at 3 to 4 months of age lumbar lordosis – lumbar sectionsbegins to develop as a child learns to walk
Scoliosis• Abnormal, side-to-side curvature of the spine – Deviation from normal vertical line – At least 10 angulation• Vertebral rotation Pedicle position
Clinical features• Obvious skewed back• Rib hump in thoracic curve• Asymetry prominence of 1 hip (thoracolumbar curves)• Skin pigmentation• Look for congenital abnormalities• Scapula level• Breast and shoulder level• Lower limbs length• Cardiopulmonary function
• Adam’s test (bend forward)• Scoliometer : measures angle of trunk rotation (ATR) 98% of curves > 20 have ATR of at least 5 •Fairly high false positive •High sensitivity, low specificity
Cobb’s angle• Maximal angle from the superior endplate of the superior-end vertebra to the inferior endplate of the inferior inferior-end vertebra.• Major factor in the clinical decision-making process.
Curve Progression • Will not progress after skeletal <30 maturity • Progress 10 -15 in lifetime30 -50 • Progress about 1 per year >50 • Affect cardiopulmonary >90 function
Risser’s sign• Iliac apophyses – Ossification from lateral to medial – Starts ossify shortly after puberty• Skeletal maturity curve progresses the most during period of rapid skeletal growth• When fusion complete (spinal maturity has been reached) coincides with fusion of vertebral ring apophyses• Further increase in curvature is neglegable (stage 5)
Postural scoliosis• Deformity is secondary or compensatory to some condition outside the spine (nonstructural/compensatory) – Short leg – Pelvic tilt (due to contracture of the hip) – Local muscle spasm associated with PID (sciatic scoliosis)• sit/ bend forward usually• Usually temporary and disappears treat underlying cause
Infantile (0-3 years old) Idiopathic Juvenile (4-9 scoliosis years old)Neuropathic and Adolescent (10 myopathic years to scoliosis maturity) Congenital scoliosis
Congenital scoliosis• present at birth• usually is due to a deformity in 1 or more vertebrae.• Associated with other congenital anomalies• Overlying tissues angiomas,naevi, excess hari, dimples, fatpad or spina bifida• Clinical examinations and imaging to – Discover other congenital anomaly – To assess the risk of spinal cord damage (e.g: cord tethering which must be dealt prior to curve correction)
Congenital Scoliosis Defects of • Block vertebrasegmentation • Unilateral bar Defects of • Hemivertebra Formation • Wedge vertebra
Neuropathic and myopathic scoliosisDiseases: Deformity of the spine often severe• cystic fibrosis in patients with neuromuscular• various types of scoliosis muscular dystrophy• spina bifida The greatest problem loss of• cerebral palsy stability and balance sitting difficult• Marfan syndrome• rheumatic disease X-ray with traction applied shows• myelomeningocele extend to which the deformity is• tumors correctable
Idiopathic scoliosis• 80% of all scoliosis• > 10 curve• No identifiable cause• Three different groups – Infantile (0-3 years old) – Juvenile (4-9 years old) – Adolescent (10 years to maturity)• Simpler division – Early onset (before puberty) – Late onset (after puberty)
Idiopathic scoliosisInfantile Idiopathic Juvenile Idiopathic Late onset (Adolescent)Scoliosis Scoliosis • Primary thoracis curves are• Males • 12-21% of idiopathic usually convex to the right• Most curves spontaneously scoliosis • Lumbar curve to the left resolve • 3-6 years: male = female • Intermediate• Surgical intervention can • 6-10 years: female:male 10:1 (thoracolumbar) and result in: Significantly • Curve progression is combine (double primary) shortened trunk common can also occur • 70% require some form of • Curve < 20 either resolve treatment spontaneously or remain unchanged
Predictor for progressions• Very young age• Marked curvature• An incomplete Risser’s sign at presentation• In pre-purbertal, rapid progression is liable at growth spurt
Warning Signs Prompting Extensive Evaluation• Convex left thoracic curve• Severe, large curves in very young children• Scoliosis in boys• Painful Scoliosis• Sudden rapid curve progression in a previously stable curve• Extensive curve progression after skeletal maturity is• reached• Abnormal neurological findings• Small, hairy patch on the lower back
Treat or Not to Treat? Observation Bracing Surgical intervention Prevent mild deformity from becoming severe. To correct an existing deformity that is unacceptable to the patient
Non-operative treatmentBracing treatment of progressive scoliotic curve 20 -30• Wear 23 hours and does not preludes full daily activities including sports and exercis
Milwaukee brace• Thoracic support -- pelvic corset connected to adjustable steel supports to cervical ring carrying occipital and chin pad• Purpose to reduce lumbar lordosis and encourage active stretching and straightening of the thoracic spine
Boston Braces•Sug fitting underarm bracethat provided lumbar or lowthoracollumbar support
Problems with Braces• Argued efficacy • Most orthopaedics surgeon waits until the curve progress to the stage when corrective surgery is justified• Narrow treatment window to initiate – Bracing will not improve the curve stop it from getting worse – Bracing has not proven to be effective for older adolescents• Poor compliance• Must have good orthotist – Proper education (How and when)
Surgical Indications• Curve > 30 that cosmetically unacceptable especially in pre-pubertal children who are liable to develop marked progression during growth spurt• Milder deformity that is deteriorating rapidly • To halt progression of the deformity • To straightened the curve (including Objectives rotational component) • To arthrodese the entire primary curve by bone grafting
Surgical treatment• Anterior fusion (ASF) – Single rod – Double rod• Posterior fusion (PSF) – Hooks – Hooks and pedicle screws – All pedicle screws.• ASF/PSF
References• Apley’s Orthopaedics Textbooks, 2010• Scoliosis: Review of diagnosis and treatment, J.A Janicki, and B. Alman, Paediatr Child Health. 2007 November; 12(9): 771–776.• Spinal Curves and Scoliosis, S. Anderson, September/October 2007, Vol. 79/No. 1 RADIOLOGIC TECHNOLOGY• Patterns of presentation of congenital scoliosis, S Mohanty & N Kumar, Journal of Orthopaedic Surgery 2000, 8(2): 33–37.