subroto scoliosis

1. SCOLIOSIS
BY
SUBROTO SAPARDAN
POST GRADUATE COURSE FKUI 11-13 OCTOBER 2003

2. ETIOLOGY
I. GENETICS
• TWIN STUDIES
• FIRST DEGREE RELATIVES- 11 %
AFFECTED
• SEARCH FOR RESPONSIBLE GENES
I. TISSUE DEFICIENCIES
• BONE - OSTEOPENIA
• MUSCLE - CALCIUM METABOLISM
• LIGAMENT/DISC

3. ETIOLOGY
III. VERTEBRAL GROWTH
ABNORMALITIES
• PROGRESSION RELATED TO
GROWTH
• FASTER ANTERIOR GROWTH –
HYPOKYPOSISS -ROTATIONAL
BUCKLING OF SPINE
• AIS PATIENTS TALLER THAN PIERS
• INCREASED GROWTH HORMONE
(PETERNEWTON SANDIEGO)

4. ETIOLOGY
IV. CNS THEORIES
• MANY NEUROMUSCULAR
CONDITION
• SYRINX ASSOCIATED WITH
SCOLIOSIS
• MELATONIN DEFICIENCY
• PINEALECTOMIZED CHICKENS

5. PREVALENCE
• >300
CURVE: 1-3/1000, M : F = 1 : 8
• CURVE PROGRESSION IN
ADULTHOOD
–RARE IF < 30O
–COMMON IF
• >50-750
THORACIC
• >30-400
LUMBAR 1 /YEAR
• BACK PAIN HIGHER RATE THAN
CONTROLS

6. PATIENT EVALUATION
• ADAMS FORWARD BENDING TEST
• LOOK-FEEL-MOVE
WALKING, STANDING (BACK, SIDE,
FRONT), FORWARD BENDING,
FLEXIBILITY, NEUROLOGICAL
EXAMINATION

7. IMAGING
• STANDING PA / STAGNARA VIEW
• LATERAL: SAGITTAL DEFORMITY
• BENDS FILMS
– SIDE BENDING, FULCRUM BENDING
• MRI :
– AGE < 10, LEFT THORACIC,
NEUROLOGICAL FINDINGS

8. NON OPERATIVE TREATMENT
I. OBSERVATION < 20-250
IMMATURE
II. ORTHOSIS CURVE > 20-250
< 40-500
IMMATURE, RISSER < 3
BOSTON TYPE/MILWAUKEE
III. EXERCISE :
NO EVIDENCE TO SUPPORT THIS
ALONE
BENEFICIAL IN BRACED PATIENTS

9. AIS : CURVE CLASSIFIKATION
LOCATION OF APEX
 CERVICO-THORACAL : C7-T1/2 DISC
 THORACIC : T2 – T11/12 DISC
 THORACO-LUMBAR : T12-L1
 LUMBAR : L1/2 DISC- L4
 LUMBOSACRAL : L5-S1

10. LENKE, BETZ, HARMS
JBJS 2001
CURVE PT MT TL.L CURVE TYPE
1 NS S NS MAIN THORACIC (MT)
2 S S NS DOUBLE THORACIC (DT)
3 NS S S DOUBLE MAJOR (DM)
4 S S S TRIPLE MAJOR (TM)
5 NS NS S TL/L
6 NS S S TL/L-MAIN THORACIC
CURVE TYPES (1-6)

11. LUMBAR CURVE MODIFIER :
• POSITION OF CENTER SACRAL VERTICAL
LINE (CSVL) TO APEX OF LUMBAR CURVE
SAGITTAL THORACIC MODIFIER :
• T5-T12 SAGITTAL COBB
- : <100
N : 10 – 400
+ : > 400

12. CURVE CLASSIFICATION
CURVE TYPE (1-6)
+
LUMBAR CURVE MODIFIER (A,B OR C)
+
SAGITTAL THORACIC MODIFIER(-,N,+)
CURVE CLASS : 1A-,1AN, 6CN, 6C+

13. LENKE
• TYPE I : MT - PSSI OR ASSI
• TYPE II : DT- PSSI- PT + MT
• TYPE III : DMC – PSSI- MT+TL/L
MT ONLY < 600
MT RIGID
INFORMED CONSENT
SAFE L4 STOP AT L3

14. LENKE
• TYPE IV : TMC – PSSI – PT, MT,TL/L
• TYPE V : TL/L – ASSI TL/L ALONE
• TYPE VI : TL/L + MT
PSSI MT + TL/L

15. METHODS

16. METHODS

17. METHODS

18. METHODS
THE 6,35 MM
STAINLESS STEEL
ROD IS
PREBENDED IN
KYPHOSIS IN THE
THORACIC SPINE
AND LORDOSIS IN
THE LUMBAR SPINE

19. METHODS
THE ROD IS
PLACED IN 450
TO
60TOWARDS THE
CONCAVE SIDE
FROM THE
MIDSAGITTAL
PLANE

20. METHODS
DISTRACTION WITH
THE SPREADER UNTIL
THE HOOKS ARE
LOCKED IN PLACE
WITH THE ANTI
ROTATION SYSTEM

21. METHODS
THE SUBLAMINAR WIRES
ARE TIGHTENED ONE BY
ONE GRADUALLY UNTIL
THE CURVE CORRECTED
BY PERIAPICAL
TRANSLATION FOLLOWING
THE LEEDS METHOD AND
THE SCOLIOSIS IS
CONVERTEDINTO NORMAL
KYPHOSIS

22. METHODS

23. METHODS
THE CORRECTED
DEFORMITY IS
NEUTRALIZED / STABILIZED
USING THE SPINAL
RECONSTRUCTION PLATE
WITH SEGMENTAL
PEDICLE SCREWS

24. METHODS
IN KING TYPE 1 CURVES AND LENKE
TYPE 5 AND 6 THE ROD HAS TO BE
CONTOURED AS AN “ S ” SHAPED BOTH
IN THE SAGITTAL AND CORONAL PLANE
WITH THE RECONSTRUCTION PLATE
AND FORMS A CROSSED INSTR.

25. METHODS
THIS
INSTRUMENTATION
IS NAMED THE UI
SYSTEM AFTER
UNIVERSITY OF
INDONESIA WITH
PATENT PENDING
NO. P 00200200388

26. PATIENTS
 FEB. 1998 – NOV. 2000
 54 AIS MEAN AGE 17,5 YEARS
MEAN CURVE SEVERITY 72,2 DEGREES
 MEAN CORRECTION 68,6%

27. FEB 1998 – DEC 2002
94 PTS

28. RESULTS
 FOLLOW UP 2 YEARS
 MEAN CORRECTION 68,6%
 ALL COMPENSATED
 NO HYPOKYPHOSIS
 PATIENT’S / PARENT’S
SATISFACTION 85/100

29. COMPLICATIONS
 INSTRUMENTATION FAILURE Θ
 2 DEEP LATE INFECTION
→ REMOVAL OF INSTR.

30. F, 14 y o, Lenke 1 A -
T5-T11 110/87  58

31. T5-T11 110/87  58

32. F, 31 y o, Lenke 1 A-
T4 – T12 84/72  42

33. T4 – T12 84/72  42

34. F, 12 y 0 Lenke 3 C n T4 – T11R
80/61  30 T11 L4 L 66/35 21
Crossed UI system

35. F 14, Lenke 5 C+,
T11-L3 135/105  58

36. Kyphosis 90  36,
Rotational hump 6  1,5

37. T11-L3 135/105  58

38. T11-L3 135/105  58

39. CONCLUSIONS :
 THE UI SCOLIOSIS SYSTEM
* GOOD 3 DIMENSIONAL
CORRECTION
* STABLE INSTRUMENTATION
(NO EXTERNAL SUPPORT REQUIRED)
* INEXPENSIVE
 OFFERS GOOD – EXCELLENT
COSMESIS IN A BALANCED
SPINE