Scoliosis and Kyphosis Donald S. Corenman, M.D., D.C.
Biomechanics <ul><li>Bipedal locomotion ability from sagittal and coronal balance </li></ul><ul><li>Minimal expenditure of...
Normal Alignment <ul><li>Coronal balance- no more than 10 º of lateral curvature </li></ul><ul><li>Thoracic kyphosis- 20-4...
Classification of Scoliosis- 1 <ul><li>Structural </li></ul><ul><ul><li>Idiopathic (Infantile 0-3) (juvenile 3-10) (Adoles...
Classification of Scoliosis- 2 <ul><li>Nonstructural Scoliosis </li></ul><ul><ul><li>Postural </li></ul></ul><ul><ul><li>H...
Classification of Kyphosis <ul><li>Postural </li></ul><ul><li>Scheuermanns </li></ul><ul><li>Congenital </li></ul><ul><li>...
Glossary of Terms <ul><li>Cobb Measurement- measurement of lines perpendicular to transverse axis </li></ul><ul><li>Café a...
Patient Evaluation- 1 <ul><li>How was deformity first noted? </li></ul><ul><li>Any increase in the deformity? </li></ul><u...
Patient Evaluation- 2 <ul><li>General health, developmental milestones (including health of the mother ;drugs, perinatal p...
Physical Examination- 1 <ul><li>Patient must be examined front and back </li></ul><ul><li>Height and weight </li></ul><ul>...
Spinal Dysraphysm
Physical Examination-2 <ul><li>ROM of the spine in all planes- look for flexibility of the curve </li></ul><ul><li>Where i...
 
Physical Examination- 3 <ul><li>Maturity assessed- breast development (Tanner scale), pubic and axillary hair </li></ul><u...
Scoliometer <ul><li>Measures asymmetrical truncal rotation (ATR) </li></ul><ul><li>ATR of 5 º should be referred after sec...
Incidence and Natural History <ul><li>Schands and Eisenberg- chest minifilms on TB screens- >10 º: 1.9%, >20º: 0.5% </li><...
Incidence and Natural History- 2 <ul><li>Treatment depends upon amount of growth remaining and size of the curve </li></ul...
Risser Sign
Alternative Treatments <ul><li>Electrical muscle stimulation- proven ineffective </li></ul><ul><li>Traction and antigravit...
Adolescent Idiopathic Scoliosis Brace Treatment <ul><li>Single left thoracic curve is suspicious </li></ul><ul><li>Treat c...
Adolescent Idiopathic Scoliosis Brace Treatment- 2 <ul><li>Brace is worn full time but for PE, bathing and sports (20-22 h...
Orthotics <ul><li>Goals: initially improve deformity and prevent curve progression, allow social and physical development ...
End of Orthosis Treatment <ul><li>Wean from brace at end of growth (no height increase, Risser 4, 12-18 mo post menarche <...
Juvenile Kyphosis <ul><li>Normal 20-45 º (greater than 50- excessive) </li></ul><ul><li>Kyphosis in thoracolumbar junction...
Sagittal profile of Scheuermanns
Scheuermann’s <ul><li>Most patients who present, present with deformity </li></ul><ul><li>Pain in 20-60% (increased with t...
Scheuermann’s Radiographic Findings <ul><li>Vertebral wedging (Sorenson- 5 º in 3 consecutive vertebra) </li></ul><ul><li>...
Postural Roundback vs. Scheurermann’s <ul><li>Postural roundback- curve only 40-60 º </li></ul><ul><li>Unassociated with m...
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Treatment for scoliosis | curvature of the spine | thoracic kyphosis | Spine Surgeon in Colorado

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Dr. Donald Corenman, M.D., D.C. (http://neckandback.com 970-479-5895), is a spine surgeon in Colorado who specializes in conditions of the spine including degenerative conditions, traumatic and sports injury. He is also a well-known expert on the treatment for scoliosis. Scoliosis is a curvature of the spine. Thoracic kyphosis is also a spinal defect marked by a curvature of the spine. Both scoliosis and thoracic kyphosis are congenital conditions.

This presentation focuses on scoliosis and kyphosis. It discusses how scoliosis and kyphosis are classified, offers an insight into the treatment for scoliosis and provides an in-depth look at the anatomic structure of the spine in relation to these congenital disorders.

Dr. Corenman is a renowned spine surgeon in Colorado. He is a spine expert at the Steadman Clinic in Vail, Co and he has written countless medical articles on spine conditions and the surgical options that are available today. He recently launched his own website (http://neckandback.com) to educate patients on spine disorders and to offer second opinions to physicians and colleagues who are seeking additional information on specific spine injuries and treatment options.

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  • The Department of Spine Surgery at Primus Super Speciality Hospital is running one of the Best Spine Care Programs in the country and is manned by a team of dedicated spine surgeons who provide state of the art and evidence based spine services to the patient. Primus Super Speciality Hospital 2, chandragupt Marg, Chanakyapuri, New Delhi- 110021, India 01166206640, 9953722892 info@primushospital.com http://www.primushospital.com/spine-center.html
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Treatment for scoliosis | curvature of the spine | thoracic kyphosis | Spine Surgeon in Colorado

  1. 1. Scoliosis and Kyphosis Donald S. Corenman, M.D., D.C.
  2. 2. Biomechanics <ul><li>Bipedal locomotion ability from sagittal and coronal balance </li></ul><ul><li>Minimal expenditure of energy for locomotion </li></ul><ul><li>Upper limbs are now free for other complex tasks </li></ul><ul><li>Pathological contours cause malfunction, increased energy usage, abnormal loading and therefore, premature wear </li></ul><ul><li>Visceral deterioration and neurological compromise may occur </li></ul>
  3. 3. Normal Alignment <ul><li>Coronal balance- no more than 10 º of lateral curvature </li></ul><ul><li>Thoracic kyphosis- 20-40º (elderly can increase 5º </li></ul><ul><li>Lumbar lordosis- 40-60º </li></ul>
  4. 4. Classification of Scoliosis- 1 <ul><li>Structural </li></ul><ul><ul><li>Idiopathic (Infantile 0-3) (juvenile 3-10) (Adolescent >10) </li></ul></ul><ul><ul><li>Neuromuscular (UMN: CP, Spinocerebellar, Syringo, cord tumor and trauma) (LMN: Polio, trauma, myelomengiocele, dysautonomia) </li></ul></ul><ul><ul><li>Myopathic (arthrogryposis, dystrophies, etc) </li></ul></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Trauma, tumors etc </li></ul></ul>
  5. 5. Classification of Scoliosis- 2 <ul><li>Nonstructural Scoliosis </li></ul><ul><ul><li>Postural </li></ul></ul><ul><ul><li>Hysterical </li></ul></ul><ul><ul><li>Nerve root irritation (antalgic) </li></ul></ul><ul><ul><li>Inflammatory (appendicitis) </li></ul></ul><ul><ul><li>Leg length discrepency </li></ul></ul><ul><ul><li>Hip contracture </li></ul></ul>
  6. 6. Classification of Kyphosis <ul><li>Postural </li></ul><ul><li>Scheuermanns </li></ul><ul><li>Congenital </li></ul><ul><li>Neuromuscular </li></ul><ul><li>Traumatic </li></ul><ul><li>Iatrogenic </li></ul><ul><li>Postirradiation </li></ul><ul><li>Metabolic (includes osteoporotic) </li></ul><ul><li>Dysplasias, tumors, inflammatory (ankylosing spondylitis) </li></ul>
  7. 7. Glossary of Terms <ul><li>Cobb Measurement- measurement of lines perpendicular to transverse axis </li></ul><ul><li>Café au lait spots </li></ul><ul><li>Fractional Curve- correcting curve to horizontal </li></ul><ul><li>Gibbus- sharp angulated kyphus </li></ul><ul><li>Nonstructural curve- curve that corrects or overcorrects on sidebending </li></ul><ul><li>Pelvic obliquity- deviation of the pelvis from horizontal- cause can be above or below </li></ul>
  8. 8. Patient Evaluation- 1 <ul><li>How was deformity first noted? </li></ul><ul><li>Any increase in the deformity? </li></ul><ul><li>Any previous treatment? Brace? Compliance? Surgery? </li></ul><ul><li>Pain? (In children and adolescents, deformity is not accompanied by pain) </li></ul><ul><li>Neurologic symptoms? </li></ul>
  9. 9. Patient Evaluation- 2 <ul><li>General health, developmental milestones (including health of the mother ;drugs, perinatal problems) </li></ul><ul><li>Family History </li></ul><ul><li>Maturity (girls- pubic hair at rapid growth, boys- before rapid growth) Menarche indicates decreased growth and occurs 2 years later. Axillary hair decreasing growth velocity </li></ul>
  10. 10. Physical Examination- 1 <ul><li>Patient must be examined front and back </li></ul><ul><li>Height and weight </li></ul><ul><li>Cornea (clouding in mucopolysaccharidosis), Palate (high in Marfans), Ear (congenital anomolies), neck (webbing in Turners) </li></ul><ul><li>Observe back- asymmetries in shoulders, scapulae, waist, obvious deformity?, Balance of thoracic spine over pelvis (C7 plumb to gluteal cleft) </li></ul>
  11. 11. Spinal Dysraphysm
  12. 12. Physical Examination-2 <ul><li>ROM of the spine in all planes- look for flexibility of the curve </li></ul><ul><li>Where is pain present? </li></ul><ul><li>View patient from the side for sagittal contours (+ or – sagittal deformity and hypo/hyperlordosis) </li></ul><ul><li>Adams position- asymmetry measured with a scoliometer- sharp or gentile contours (tight hamstrings- spondylo) </li></ul><ul><li>Inspect skin- hair patches, dimples, nevi, chest for pectus carniatum/ excavatum </li></ul>
  13. 14. Physical Examination- 3 <ul><li>Maturity assessed- breast development (Tanner scale), pubic and axillary hair </li></ul><ul><li>Joint flexibility </li></ul><ul><li>Lower extremity deformity or contraction </li></ul><ul><li>Neurological examination (superficial abdominal reflex only abnormal finding in syringomyelia that mimics idiopathic scolio) </li></ul><ul><li>Leg length </li></ul><ul><li>Mental Status </li></ul>
  14. 15. Scoliometer <ul><li>Measures asymmetrical truncal rotation (ATR) </li></ul><ul><li>ATR of 5 º should be referred after second screening </li></ul><ul><li>ATR of 8º should be immediately referred </li></ul>
  15. 16. Incidence and Natural History <ul><li>Schands and Eisenberg- chest minifilms on TB screens- >10 º: 1.9%, >20º: 0.5% </li></ul><ul><li>Duhaime et all; 1.1% </li></ul><ul><li>Lonstein; 1.1% </li></ul><ul><li>Nilsonne and Lundgren; Decreased work capacity, 76% women unmarried, 47% disabled </li></ul><ul><li>Nachemson; mortality 2X normal, 25% disabled </li></ul><ul><li>Collis and Ponseti; not as bad as above </li></ul>
  16. 17. Incidence and Natural History- 2 <ul><li>Treatment depends upon amount of growth remaining and size of the curve </li></ul><ul><li>Lonstein; Curves between 20-29 º and Risser 0-1 will progress 68% of time, </li></ul><ul><li>Carman: Cobb measurement intraobserver error of 31% for 5º and 4% for 10º </li></ul><ul><li>Curves >45º in immature will need surgery </li></ul>
  17. 18. Risser Sign
  18. 19. Alternative Treatments <ul><li>Electrical muscle stimulation- proven ineffective </li></ul><ul><li>Traction and antigravity- proven ineffective for definitive treatment </li></ul><ul><li>Chiropractic- proven ineffective </li></ul><ul><li>Medication- proven ineffective </li></ul><ul><li>Exercise therapy- normally used in conjunction with brace but by itself is ineffective </li></ul>
  19. 20. Adolescent Idiopathic Scoliosis Brace Treatment <ul><li>Single left thoracic curve is suspicious </li></ul><ul><li>Treat curves using orthosis 30-40 º immediately or 20-29º with proven progression (>5º) </li></ul><ul><li>Curve must be cosmetically acceptable </li></ul><ul><li>Cannot use brace in thoracic lordosis </li></ul><ul><li>Curves less than 20º may not progress </li></ul><ul><li>Patient must be skeletally immature (Risser 0-2, postmenarchaeal less than 1 year) </li></ul>
  20. 21. Adolescent Idiopathic Scoliosis Brace Treatment- 2 <ul><li>Brace is worn full time but for PE, bathing and sports (20-22 hours/ day) </li></ul><ul><li>Brace should correct curve 50% while on </li></ul><ul><li>Brace should flatten lumbar lordosis </li></ul>
  21. 22. Orthotics <ul><li>Goals: initially improve deformity and prevent curve progression, allow social and physical development </li></ul><ul><li>CTLSO (Milwaukee brace)- gold standard for scoliosis and hyperkyphosis </li></ul><ul><li>Curves below T7 can use TLSO- above need Milwaukee </li></ul><ul><li>Complications- increased intragastric pressure/ reflux, psychological </li></ul>
  22. 23. End of Orthosis Treatment <ul><li>Wean from brace at end of growth (no height increase, Risser 4, 12-18 mo post menarche </li></ul><ul><li>Standing PA X Ray 4 hours out of brace and compare to last in-brace film </li></ul><ul><li>If no significant change, out of brace 4 hours daily </li></ul><ul><li>Protocol repeated every 4 months until child is only sleeping in the brace (last 6-12 months of Rx) </li></ul><ul><li>Take radiograph at 1 full week out of brace </li></ul>
  23. 24. Juvenile Kyphosis <ul><li>Normal 20-45 º (greater than 50- excessive) </li></ul><ul><li>Kyphosis in thoracolumbar junction or lumbar spine is abnormal </li></ul><ul><li>Scheuermann’s- mechanical factors, familial occurrences, Thickened ALL </li></ul><ul><li>Males = females </li></ul><ul><li>Onset 10-12 years of age </li></ul>
  24. 25. Sagittal profile of Scheuermanns
  25. 26. Scheuermann’s <ul><li>Most patients who present, present with deformity </li></ul><ul><li>Pain in 20-60% (increased with thoracolumbar forms) </li></ul><ul><li>Can predispose patient to spondylolysis </li></ul><ul><li>PE notes more rigid thoracic curve with a supple lumbar curve </li></ul>
  26. 27. Scheuermann’s Radiographic Findings <ul><li>Vertebral wedging (Sorenson- 5 º in 3 consecutive vertebra) </li></ul><ul><li>Schmorls nodes </li></ul><ul><li>Irregular endplates </li></ul><ul><li>Mild scoliosis (10-20) with or without rotation seen in 20-30% of patients </li></ul>
  27. 28. Postural Roundback vs. Scheurermann’s <ul><li>Postural roundback- curve only 40-60 º </li></ul><ul><li>Unassociated with muscle contraction </li></ul><ul><li>Supple, easily correctable </li></ul><ul><li>No vertebral irregularities (normally don’t show until 10-12 years- could be early Scheuermann’s) </li></ul>
  28. 29. Thank You

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