• تشوه العمود الفقري / الجنف / استشاري جراحة العمود الفقري في الاردن / علاج مرضى العمود الفقري بطرق جراحية وغير جراحية / جراحة العمود الفقري بالتداخل المحدود / عمليات الديسك / "الديسك" أو الإنزلاق الغضروفي / علاج الديسك / عمليات الديسك / الم الظهر من الديسك / جراحات الديسك / علاج الديسك في الاردن / اطباء الديسك / اطباء الديسك في الاردن / اسباب الديسك / الام الديك / الام العامود الفقري / اسباب الانزلاق الغضروفي / اوجاع الديسك / اعراض الديسك / علاج الديسك / افضل اطباء الديسك في الاردن / اسرع علاج ديسك في الاردن / افضل طبيب لعلاج الانزلاق الغضروفي / افضل طبيب لعلاج انزلاق الغضروفي في الاردن / كسور الفقرات / قوس العمود الفقري عند الكبار / حقائق عن آلام الظهر والديسك / عمليات تحرير العصب / ألم الظهر المزمن علاج ألم الظهر المزمن / لانزلاق الغضروفي / عندي آلام شديدة في أسفل / خدران في اليد / خدران او تنميل اليد / خدران الرجل / خدران الساق / خدران الاطراف / تنميل الاطراف / تنميل اليد / رجوع الديسك

1. ScoliosisScoliosis
Freih Odeh Abu Hassan
F R C S (Eng ) F R C S (Tr & Orth )F.R.C.S.(Eng.), F.R.C.S.(Tr.& Orth.).
Professor of OrthopedicsProfessor of Orthopedics
University of Jordan Hospital - Amman
1/16/2011 1
Professor Freih Abuhassan- University of
Jordan

2. 1-Idiopathic
–Infantile (0-3 years)
–Juvenile (4-9 years)( y )
–Adolescent (10+ years)
–AdultAdult
2- Congenital
Failure of formation–Failure of formation
–Failure of segmentation
Mi d–Mixed
1/16/2011 2
Professor Freih Abuhassan- University of
Jordan

3. 3-Neuromuscular
MyopathicMyopathic
AMC
M dystrophy
NeuropathicNeuropathic
UMNL
LMNL
Dysautonomia (Riley-Day Synd.)y ( y y y )
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Professor Freih Abuhassan- University of
Jordan

4. 4-Others
N fib t iNeurofibromatosis
Mesenchymal (Marfan’s,Mesenchymal (Marfan s,
Ehlers-Danlos)
T tiTraumatic
TumorsTumors
Skeletal dysplasia
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Professor Freih Abuhassan- University of
Jordan

5. Idiopathic Scoliosis
= 80% of scoliosis
= Familial= Familial
= 3 per 1000 of the population
has >20 degree curve.
= One in 20 children have some degreeOne in 20 children have some degree
of deformity of their spine
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Professor Freih Abuhassan- University of
Jordan

6. Types of Idiopathic Scoliosis
1- Infantile
0 3 ( l t)= 0-3 years age (early onset)
= 60% Male, 90% left sided thoracic
curves common
= Plagiocephaly
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Professor Freih Abuhassan- University of
Jordan

7. = risk for cardio-pulmonaryrisk for cardio pulmonary
compromise 10-20%
= 80-90% resolve non-progressive80-90% resolve, non-progressive.
= If rib-vertebra angle > 25 degree (Mehta)
Progressive Milwakee braceProgressive Milwakee brace
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Professor Freih Abuhassan- University of
Jordan

8. 2- Juvenile
- 4-9 years age
P i- Progressive
- !! need fusion before maturity- !! need fusion before maturity.
-26% cord pathologyp gy
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Professor Freih Abuhassan- University of
Jordan

9. 3- Adolescent
* Commonest
* 10 t it (l t t)* 10y - maturity (late onset)
* F > M 6:1F > M 6:1
* Right thoracic 90%
* 50% require surgery
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Professor Freih Abuhassan- University of
Jordan

10. Progression related to
= Female sexFemale sex
= Younger age at diagnosis
Si ifi t t ti= Significant rotation
= Single thoracic curveg
= Large curve > 25 degree
= Risser 0 1= Risser 0-1
= Family historyy y
= Growth spurt
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Professor Freih Abuhassan- University of
Jordan

11. Other Adolescent Types
A- Thoracolumbar curveso aco u ba cu ves
# > in females , > to the right
B- Lumbar Curves
# > in females# > in females
# 80% to the left
# no rib hump presented late# no rib hump presented late
C- Double major curvesC- Double major curves
# bad x-ray but well balanced curves
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Professor Freih Abuhassan- University of
Jordan

12. 4- Adult Scoliosis
Prevalence:Prevalence:
6-35% persons >50 years oldp y
2.5% patients >20 years old
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Professor Freih Abuhassan- University of
Jordan

13. Total # patients 64Total # patients = 64
Sex: 17 male 47 femaleSex: 17 male 47 female
Age mean 62yrs (range 25-87y)
Symptoms 73 %
Back pain 69 %Back pain 69 %
Leg pain 32 %
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Professor Freih Abuhassan- University of
Jordan

14. 1/16/2011 14
Professor Freih Abuhassan- University of
Jordan

15. 1- Forward bending test
2- Scoliometer2- Scoliometer
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Professor Freih Abuhassan- University of
Jordan

16. Screening problemsg p
1- Over referral
2-Radiation
3-Lack of parents compliance
4 C t4-Cost
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Professor Freih Abuhassan- University of
Jordan

17. = Birth, development, medical history
= Any symptoms or pain= Any symptoms or pain
= Skeletal age.
= Female: Onset of menses
= Family historyFamily history
Onset course, evolution of deformity
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Professor Freih Abuhassan- University of
Jordan

18. 1/16/2011 18
Professor Freih Abuhassan- University of
Jordan

19. 1/16/2011 19
Professor Freih Abuhassan- University of
Jordan

20. Standing ( back and front)Standing ( back and front)
1-any curve ( describe it)
2-loins
3- Shoulder (one elevated shoulder)
4-Skin:
h i t hhairy patches
café au lait spots
Sacral dimplesp
Spina bifida
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Professor Freih Abuhassan- University of
Jordan

21. 1/16/2011 21
Professor Freih Abuhassan- University of
Jordan

22. 5-Pelvis ( rotation, one side
elevated)
6 M i f b6-Maturity of breasts
7 Ant chest aymmetry7- Ant. chest aymmetry
7- Axillary hair7- Axillary hair
8- Voice in male8 Voice in male
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Professor Freih Abuhassan- University of
Jordan

23. Standing ( lateral)
•Kyphosis
l d i•lordosis
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Professor Freih Abuhassan- University of
Jordan

24. F d b diForward bending test
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Professor Freih Abuhassan- University of
Jordan

25. Spinal mobility :
= Side bendingSide bending
= Traction
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Professor Freih Abuhassan- University of
Jordan

26. Spine
Palpated defects
Range of motion, Flexibility
Rotation, Rib hump
lower extremityy
Leg length, Deformity
Pelvic obliquityq y
Neurologic
Strength, Sensation, Reflexes, ClonusStrength, Sensation, Reflexes, Clonus
Abdominal reflexes
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Professor Freih Abuhassan- University of
Jordan

27. Plumb linePlumb line
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Professor Freih Abuhassan- University of
Jordan

28. OthersOthers
A- Ht, Wt,
B- Relative proportions.
C Mental PsychologyC- Mental, Psychology.
D-Signs of Syndromic or hereditary
disorders
E- Cardio-pulmonary functionE- Cardio-pulmonary function
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Professor Freih Abuhassan- University of
Jordan

29. 1- Renal ultrasounds1- Renal ultrasounds
2-Cardiac assesment
3-Pulmonary function test
4 Clinical photograph4-Clinical photograph
5-Muscle biopsyp y
6- NCS
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Professor Freih Abuhassan- University of
Jordan

30. Plain Radiographs
* Indicated in allIndicated in all
* Full length standing PA and Lateral.
= Analyze
Deformity Pathology AnomaliesDeformity, Pathology ,Anomalies,
Defects, Bone lesions ,
Quantify scoliosis kyphosis lordosisQuantify scoliosis, kyphosis, lordosis.
Tanner staging to determine future growth
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Professor Freih Abuhassan- University of
Jordan

31. Plain Film Radiograph
Initial evaluation:
Plain Film Radiograph
Standing PA and lateral films.
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Professor Freih Abuhassan- University of
Jordan

32. Plain Film RadiographPlain Film Radiograph
Flexibility of the curve is evaluatedFlexibility of the curve is evaluated
with supine side-bending films
(may only be needed preop.)
S fStanding PA studies are used for
follow-upfollow up
1/16/2011 32
Professor Freih Abuhassan- University of
Jordan

33. 1/16/2011 33
Professor Freih Abuhassan- University of
Jordan

34. Lat. films beyond initial evaluation are not
necessary unless Spondylolysis ornecessary unless Spondylolysis or
Spondylolisthesis is suspected.
Traction is used in patients with N.Mact o s used pat e ts t
disease with muscles Weakness
/paral sis that pre ents acti e side/paralysis that prevents active side-
bending.
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Professor Freih Abuhassan- University of
Jordan

35. 1/16/2011 35
Professor Freih Abuhassan- University of
Jordan

36. A i i Sk l l A Ri ’ SiApproximating Skeletal Age – Risser’s Sign
Ossification of the iliac apoph sis beginsOssification of the iliac apophysis – begins
laterally (ASIS) and progresses postero-medially
towards (PSIS) to eventually cap the entire iliac
crest.
“Risser 4”
“Risser 5”
1/16/2011 36
Professor Freih Abuhassan- University of
Jordan

37. l f di h i S li iRole of radiography in Scoliosis
Document severity
Determine skeletal maturity
Monitor progressionMonitor progression
Evaluate for non-Idiopathic causes of
li i ( i l ft ti t iscoliosis (spinal, soft tissue, systemic
pathology).
Ensure adequacy of bracing / surgery
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Professor Freih Abuhassan- University of
Jordan

38. 1/16/2011 38
Professor Freih Abuhassan- University of
Jordan

39. 1/16/2011 39
Professor Freih Abuhassan- University of
Jordan

40. Quantification of deformityQuantification of deformity
End levels of curve
Greatest degree measureableGreatest degree measureable
Follow up readings from same levels
1/16/2011 40
Professor Freih Abuhassan- University of
Jordan

41. 1/16/2011 41
Professor Freih Abuhassan- University of
Jordan

42. Cobb angle problems
1- Measure one plane deformity
2 Not accurate with large curves2-Not accurate with large curves
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Professor Freih Abuhassan- University of
Jordan

43. I di i f MRI i S li iIndications for MRI in Scoliosis
*Suspect local pathology
Tumor, Infection...
*U l*Unusual curve patterns
Left thoracic
Sh l tiSharp angulation
Unbalanced curves
*N.M type curves
R/O Chiari, Syrinx, Tethered cord,, y , ,
Diastomatomyelia
1/16/2011 43
Professor Freih Abuhassan- University of
Jordan

44. 1/16/2011 44
Professor Freih Abuhassan- University of
Jordan

45. 1/16/2011 45
Professor Freih Abuhassan- University of
Jordan

46. Idiopathic Scoliosis
Treatment approach:
Proper curve and patientProper curve and patient
assesment
1/16/2011 46
Professor Freih Abuhassan- University of
Jordan

47. Infantile:Infantile:
= Many resolve spontaneously
= Observe, if progressive (10-20%)
Brace . !!!???? early surgeryy g y
Juvenile:
M tl b= Mostly observe
= Brace if progressive or surgeryp g g y
1/16/2011 47
Professor Freih Abuhassan- University of
Jordan

48. Onset: 4-9 y
Progresses rapidly.Progresses rapidly.
Always look for
underlying diseaseunderlying disease
1/16/2011 48
Professor Freih Abuhassan- University of
Jordan

49. Apex anterior
convex
epiphysiodesis
EarlyEarly
instrumentation
without fusionwithout fusion.
1/16/2011 49
Professor Freih Abuhassan- University of
Jordan

50. 1/16/2011 50
Professor Freih Abuhassan- University of
Jordan

51. Ad l t Idi thi S li iAdolescent Idiopathic Scoliosis
ObservationObservation
Curves < 20 degrees, skeletally immature. Patient
near maturity, curves < 40 degrees.
Bracing
I t ti t > 25 dImmature patient > 25 degrees
Patient with progression > 10 degrees
Surgery
Curve ~ 45-50 degrees
M h h i i i f il dMuch growth remaining, progressive, failed
brace
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Professor Freih Abuhassan- University of
Jordan

52. for bracing to be effective
* Remaining growthRemaining growth
* Curve < 40 degrees
*Proper brace, and compliance
bracing can at best slow or stopbracing can at best slow or stop
progression,p g ,
it does not correct a deformity
1/16/2011 52
Professor Freih Abuhassan- University of
Jordan

53. S i b
Custom TLSO
Summit brace
1/16/2011 53
Professor Freih Abuhassan- University of
Jordan

54. 1/16/2011 54
Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

60. 1/16/2011 60
Professor Freih Abuhassan- University of
Jordan

61. S rgical Treatment 500
Surgical Treatment 500
When ?
# Failed bracing
# Severe curvature# Severe curvature
# Expected progressionp p g
# Beyond acceptable
d f d f itdegree of deformity
1/16/2011 61
Professor Freih Abuhassan- University of
Jordan

62. A i= Arrest progression
= Achieve balance of the spineAchieve balance of the spine
= Obtain safe degree of correction
= Ensure a fused spine
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Professor Freih Abuhassan- University of
Jordan

63. Old surgicalg
correction
1/16/2011 63
Professor Freih Abuhassan- University of
Jordan

64. Old surgical
correction
1/16/2011 64
Professor Freih Abuhassan- University of
Jordan

65. Old surgicalOld surgical
correction
1/16/2011 65
Professor Freih Abuhassan- University of
Jordan

66. Posterior Pedicle Screw
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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan 67

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

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Professor Freih Abuhassan- University of
Jordan

71. 1/16/2011 71
Professor Freih Abuhassan- University of
Jordan

72. Endoscopic Surgery
* Can permit much smaller incisions forp
surgery of the anterior spinal column.
* Faster reco er possible* Faster recovery possible.
* Less tissue damage.g
* Less blood loss possible.
1/16/2011 72
Professor Freih Abuhassan- University of
Jordan

73. Endoscopic Surgery
R l f di
Views into chest cavity
Release of disc
Views into chest cavity
With thoracoscope
1/16/2011 73
Professor Freih Abuhassan- University of
Jordan

74. S li i 1060Scoliosis 1060
Kyphosis 670
Surgical plan:Surgical plan:
Endoscopic ant. release
Post. instrumentation
1/16/2011 74
Professor Freih Abuhassan- University of
Jordan

75. Post-operative:Post operative:
Scoliosis 400
Kyphosis 450
1/16/2011 75
Professor Freih Abuhassan- University of
Jordan

76. Summary
• Proper Screening/Evaluation
= All suspicious exams X-ray evaluation.
= Thorough PE R/O non-idiopathic etiologyThorough PE, R/O non-idiopathic etiology.
= All suspicious curves MRI, CT.p ,
1/16/2011 76
Professor Freih Abuhassan- University of
Jordan

77. • Treatment
= Mild curves (100 – 250) Observe
M d t i= Moderate, progressive curves
(250-400) Brace(25 40 ) Brace
= Severe, progressive (~ 500) Surgery
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Professor Freih Abuhassan- University of
Jordan