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Scoliosis
1) Scoliosis is a lateral curvature of the spine greater than 10 degrees with rotation of the vertebrae in the frontal and sagittal planes. 2) It affects 2% of children at some point in life, with 10% requiring corrective surgery. Girls are more commonly affected than boys. 3) Scoliosis can be structural, involving vertebral abnormalities, or non-structural due to factors like posture or leg length discrepancy. Treatment options include observation, bracing, and surgery depending on the severity and progression of the curvature.
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Scoliosis
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- 2. Introduction Scoliosis isdefined as a lateral deviation of the normal vertical line of the spine >10º associated with rotation of the vertebrae. Three-dimensional deformity of the spine - sagittal, frontal, and coronal planes
- 3. ~2% ofchildren affected at some stage of life ~10% of affected patients will require corrective surgery Occurs in 1-3% of population below the age of 16 years. 0.1% have a curve greater than 40 degrees. Girls are more affected than boys. Those with a curve of more than 30 degrees are generally girls, outnumbering boys by 10:1. Statistics
- 4. Anatomy All bonyelements are altered Vertebra are wedge shaped Poorly Developed Concave side Pedicles rotated Discs are wedged as well
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- 6. • Genetic StronglyFamilial 11% incidence in first relatives of patients. • Tissue deficiencies common on Marfan’s syndrome • Growth abnormalities Asymmetrical vertebral growth • Central nervous system alteration Different size cerebral cortices. Associated Syrinx, Low lying cord, Arnold Chiari Malformation –Functional Spinal Cord Tethering Etiology
- 7. • Structural involvesboth a lateral curvature and rotation of the vertebrae. • Non- structural The spine has a lateral curvature but there is no structural abnormality in the spine. The curvature is in response to habit or a disease process. Clinical Types
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- 9. A reversiblelateral 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 Correction of the lateral curve is possible by: • Forward or side bending. This test is done to determine whether the curve straightens out as the child bends forward and to identify a visible, rotational deformity of the rib cage • Positional changes and alignment of the pelvis or spine. • Muscle contraction • By correction of a leg-length discrepancy Non-structural Scoliosis (Postural/ Functional)
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- 11. Postural– Thiscurvature is due to prolonged use of a wrong posture. It resolves when the child is lies down. Compensatory – It is caused by leg-length discrepancy. There is no rotation of the vertebrae and it usually goes off on sitting. Sciatic This curve results from trying to avoid pain from an irritated sciatic nerve Inflammatory: Here a curvature in the spine is caused by an infective process such as an appendicitis. The body curves in response to the disease or abdominal muscle spasm. Hysterical – very rare and has an underlying psychological component Non-structural Scoliosis
- 12. Classification Cervical curve– apex between C1 and C6 Cervico-thoracic curve - apex between C7 and T1 Thoracic curve - apex between T2 and T11 Thoraco-lumbar curve - apex between T12 and L1 Lumbar curve - apex between L2 and L4 Lumbosacral curve - apex between L5 and S1
- 13. King’s Classification Double curve, bothcurve cross the midline, • Lumbar curve larger , stiffer than the thoracic curve Double curve, both cross the midline • Thoracic curve larger, stiffer than the lumbar curves. Thoracic curve crosses midline and lumbar curve does not cross midline Long thoracic curve in which L5 is centered over sacrum but L4 tilts into long thoracic curve Thoracic curve and T1 tilts to upper curve
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- 15. • History Firstnoted and progression Family history Affected sibling 7 times more frequent Affected parent 3 times more frequent Recent growth history Sexual maturity Pain ‘Fatigue pain’ Post diagnostic pain ‘Severe pain’ Diagnosis
- 16. Iliac crestheight Leg length discrepancy Shoulder height Arm trunk space Scapular position Trunk shift Neuro exam /Muscle charting Generalized Features – Marfan’s Inspection of skin Café au lait spots Hair patch Physical Examination
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- 18. < 7degrees is normal Scoliometer
- 19. Posteroanterior andlateral radiographs Right and left bending films, traction films, fulcrum bending films, or push prone radiographs – flexibility Stagnara - eliminate rotational component of the curve. Radiographic parameters - to assess maturity. Hand and wrist and development of the iliac apophysis (Risser sign), triradiate cartilage, olecra- non apophysis ossification, and digital ossification Radiographic Evaluation
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- 21. Nash &Moe Vertebral Rotation
- 22. Skeletal maturity Based on ossification of iliac apophysis Graded from 0 (no ossification) to 5 (complete bony fusion) Risser Grade
- 23. Neurologic deficit •Necessary in cases of: A thoracic curve to the left. Painful scoliosis. Abnormal neurological findings. Excessive stiffness. Deviation to one side during the bend test. Sudden rapid progression of a previously stable curve. MRI
- 24. Curves 30to 50 degrees progress an average of 10 to 15 degrees over a lifetime. Curves > 50 at maturity progress steadily at a rate of 1 degree per year. Curves less than 30 at bone maturity are unlikely to progress. At 90 degrees or greater: increased potential for life threatening effects on pulmonary function. Progression
- 25. Observation Bracing Surgery Treatment
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- 27. Bracing Orthotic braces- 74% success rate at halting progression Must be worn 20-23 hours a day, but most pts are not compliant. Braces do not correct scoliosis • Contraindications Curves >450 Patient with noticeable Trunk shift Skeletally mature adolescents – Riser 4-5, 2 yrs post menarchal Curve apex above T6 Excessive Thoracic Hypokyphosis < 200
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- 29. Spinal Fusion- motion segments (vertebrae) are welded together using bone grafts, rod and screws. • Posterior approach (back) – thoracic curves • Anterior-posterior approach (front and back) • Anterior approach (front) - thoracolumbar and lumbar curves • Thoracoscopic surgery (VATS, Video-Assisted Thoracoscopic Surgery) Spinal instrumentation without fusion Surgery
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- 32. • Posterior approach required in patients with double or triple curves or curves.
- 33. • Anterior-Posterior Approach performed in patients with severe stiff curves and in young, skeletally immature patients to prevent crankshaft phenomenon. • Crankshaft Phenomenon progression and rotation of curve resulting due to growth of anterior part of the spine and fused posterior part.
- 34. • Anterior Approach thoracolumbar (thoracic-lumbar) and thoracic curves
- 35. • Growth Rods Commonly used in children Allow for straightening of the spine and subsequent lengthening procedures until the patient reaches adolescence when a final fusion procedure is performed.
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