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MODERATOR – Dr.Nandish
PRESENTER – Dr.Venkatesh Singh
DEFINITION
• “Scoliosis” - Greek word meaning “crooked.”
• Scoliosis is defined as lateral deviation of the
normal vertical line of the spine, which when
measured on a radiograph, is greater than 10
degrees ,with associated rotation of vertebrae
• Patients with curves less than 10 degrees are
considered to have spinal asymmetry
2:39 PM
Scoliosis
• The lateral curvature of the spine is associated with rotation
of the vertebrae within the curve-
• a three-dimensional deformity occurs in three
planes:
(1) lateral intervertebral tilting in the
frontal plane
(2) a rotatory component in the axial
plane
(3) intervertebral extension in the sagittal plane
leading to lordosis of the scoliotic segment
• The common right (dextro) thoracic curve,
(measuring 10°)
- considered physiologic
- to accommodate the size and position of the
heart, lung, and aorta or to be related to
handedness.
• 7 times more prevalent in females
• 80% of scoliosis origin unknown
Lateral displacement Angular displacement
Classification
 Structural ( radiographically Cobb angle of 25°
or more on ipsilateral side-bending radiographic
views)
 Non-structural - compensatory and postural
Based on aetiology :
• Idiopathic
• Congenital
• Neuromuscular
• Syndromic
AGE-BASED: (idiopathic)
 infantile(birth and 3 years)
 juvenile (3 and 10 years of age)
 adolescent (10- skeletal maturity) MC
Scoliosis
Scoliosis
Scoliosis
NON STRUCTURAL
• A reversible lateral 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
.
2:39 PM
Correction of the lateral curve is possible by:
-Forward or side bending
-Positional changes and alignment of the pelvis or spine.
-Muscle contraction
-By correction of a leg-length discrepancy
Etiology of Nonstructural scoliosis-
• Leg length discrepancy: (structural or functional)
Measurable difference because of a dislocated hip,
asymmetric leg or foot postures.
• Habitual asymmetric posture: Sitting with weight
shifted onto one hip or standing with weight
primarily supported on one leg
• Muscle guarding or spasm from a painful stimuli
in the back or neck
Scoliosis
CONGENITAL SCOLIOSIS
• Congenital scoliosis is a progressive three-
dimensional deformity of the spine caused by
congenital anomalies of the vertebrae that result in
an imbalance of the longitudinal growth of the
spine.
• the familial incidence = 1% to 5%
• more common in girls (3 : 2)
DEVELOPMENT OF SPINE
• Paraxial mesoderm on either side of the notochord -form
somites
( Somitogenesis)
Each somite subdivides further into ventral sclerotome and
dorsolateral dermomyotome.
• 4th week of development- cells from the sclerotome on each side
of the body migrate ventrally and surround the notochord
• Each vertebra is formed by sclerotome cells from two somite
levels .
• The ventral part of each vertebra forms the body around the
notochord, and the dorsal part forms costal processes laterally
and the vertebra arch dorsally.
• 6th week of development- mesenchymal cells fill the space
between two vertebral bodies to contribute to formation of the
intervertebral structures.
This stage is called Segmentation stage.
Scoliosis
Scoliosis
• Anomalies occur in 30% to 60%
• MC -the spinal cord and the genitourinary tract.
• Intraspinal anomalies include - tethered cord,
diastematomyelia, and syringomyelia.
• The most common genitourinary defects are renal
agenesis, ectopic kidney, duplication, and reflux.
• VACTERL association :
Vertebral defects (V), Anal atresia (A), Cardiac defect
(C), Tracheoesophageal fistula (TE), Radial limb
reduction, and Renal defects (R) and Limb defect (L)
• in Klippel-Feil syndrome, Marfan syndrome, Ehlers-
Danlos syndrome, Charcot-Marie-Tooth disease.
HUETER-VOLKMAN PRINCIPLE
•Hueter-Volkmannn Law:bone
growth in the period of skeletal
immaturity is retarded by mechanical
compression on the growth plate and
accelerated by growth plate tension
• the rotation of vertebral bodies in the axial
plane
• causes discrepant axial loading between the
ventrally and dorsally located portions of the
involved vertebrae
• ventrally located part of the vertebral column
becomes the concave side
• the dorsally located part becomes the convex
side of a lateral curve
NEUROMUSCULAR SCOLIOSIS
• The second most common form of scoliosis and is
associated with disorders of the nerve or muscular
systems, such as:
a)Neuropathic -
• 1)Lower motor neuron(e,g.poliomyelitis)
• 2)Upper motor neuron(e,g. cerebral palsy)
b)Myopathic -
1)Progressive(e,g. muscular dystrophy)
2)Static(e,g. Amyotonia congenita)
3)others(e,g.Friedreich’s ataxia, unilateral amelia)
• These cause muscles to become weak,
spastic or paralyzed — and unable to support
the spine, resulting in spinal curvatures.
• Treatment will depend on child's age and
underlying condition, as well as the type and
severity of the spinal curve.
IDIOPATHIC SCOLIOSIS
• Idiopathic scoliosis is the most common type of
scoliosis.
• defined as a spinal deformity characterized by
lateral bending and fixed rotation of the spine in
the absence of any known cause
• Idiopathic scoliosis is divided into three categories
based on chronologic age:
-infantile (birth to 2 years+ 11 months)
-juvenile(3 years to 9 years+11 months),
-adolescent (10 years to 17 years+11 months)
2:39 PM
INFANTILE IDIOPATHIC SCOLIOSIS
• Common in Europe
• Male predominance
• Left thoracic curve pattern is most common
• Two types have been identified: a resolving
type (85%) and a progressive type (15%)
• curves that can progress can be obtained from the
rib-vertebral angle difference (RVAD) and
“phase of the rib head.”
• If the head and neck of the convex rib of the vertebral
body at the apex of the curve does not overlap the
vertebral body, it is termed phase I
• if it does overlap, it is termed phase II.
• Curves with RVAD greater than 20 degrees or phase
II angles are very likely to progress
2:39 PM
Scoliosis
JUVENILE SCOLIOSIS
• 12%–16% of all patients with idiopathic scoliosis
• Increasing female predominance
• Most common curve patterns are right thoracic
• Approximately 70% of curves progress
ADOLESCENT SCOLIOSIS
• most common type of scoliosis in children
• A female predominance
• Thoracic curve patterns are generally convex to the
right
• Idiopathic scoliosis in adolescence is not typically
associated with severe pain
CLINICAL FEATURES
• Deformity is usually the presenting symptom
• Pain
• Rib hump or abnormal para spinal muscular
prominence (indicates spinal rotation)
(Rib hump leads to asymmetry of trunk called angle
trunk rotation (ATR) )
• Raised shoulders(thoracic curves-convex side)
(Lumbar curves – concave side)
• Scapula – rotated outwards and forwards with
elevation on convex side
• Increased flank creases – concave side
• Higher ASIS PSIS – concave side
2:39 PM
Physiological Effects of Scoliosis
• Mid-back pain
• lower back pain,
• neck pain, headaches,
• premature disc and joint degeneration
• Decreased pulmonary function
Scoliosis
Scoliosis
MANAGEMENT
Patient history
• Age at onset
• Evidence of maturation
• Back pain
• complete neurological history
• Family history
• Self-perception
Physical examination
• Height measurement
• Gait check
• Foot shape
• Skin inspection
• Assessment of pubertal development
• Neurological examination ( including motor, sensory
and reflex tests )
• Symmetry of shoulders and iliac crest
2:39 PM
Assessment of scoliosis
• the four basic spinal parameters evaluated in
scoliosis are
 curvature
 rotation
 flexibility
 skeletal maturation
SCOLIOMETRY
The Scoliometer is placed
on the back and measures
the apex (the highest point)
of the upper back curve.
`
• Plumb line - On posterior aspect, line drawn
from occiput should normally align with gluteal
cleft
ADAM’S FORWARD BEND TEST
• Simple curve-Single spinal
deviation
• Compound curve-
Displacements in Right &
Left direction
• Primary curve- Curve that
develops first
• Secondary or
Compensatory curve-
Develops as a balancing
response to the primary
curve
• Non structural curve- Curve is flexible and
corrects by bending towards convex side
STRUCTURAL
SCOLIOSIS
• Non correctable
deformity of affected
spinal segment.
• Vertebral rotation is
an essential
component
• Spinous process
swing round towards
the concavity of the
curve.
• Transverse
processes on the
convexity rotates
posteriorly.
• To determine the severity of the curve
• X-ray Antero Posterior, Lateral & Oblique view
of spine
• Right & left bending view – determine the
degree of flexibility of spine & to see how much
curve can be passively corrected
THORACIC curve – STRUCTURAL
LUMBAR curve – COMPENSATORY
2:39 PM
•The end vertebrae (E) -are
most tilted
•Apical vertebra(A)- is the
central vertebra within a curve.
It is typically the least tilted,
most rotated, and most
horizontally displaced
vertebra within a curve
•A neutral vertebra (N) -
one that is not rotated
•a stable vertebra (S)- is one
that is bisected or nearly
bisected by the CSVL (dotted
line)
Scoliosis
CURVATURE MEASUREMENT
• COBB- LIPPMANN :
• most accepted
• AP radiograph entire spine
• a line is drawn along the superior border of
the cephalad end vertebra and inferior
surface of the caudad end vertebra
• Perpendicular lines are erected from each endplate
line, and the vertical (not horizontal) angle formed by
their intersection is measured
2:39 PM
Scoliosis
Double curve
• One vertebra is upper end
vertebra for lower curve
and lower end vertebra for
upper curve (transitional
vertebra).
• Only one line drawn on
this vertebra.
King-Moe classification
• Published in 1983
• thoracic curve patterns
• five curve types as a guide to surgical treatment
• The King classification does not address lumbar
curves, thoracolumbar curves, or triple major curves.
• It does not evaluate sagittal plane alignment.
• Type 1: S-shaped curve in which both the thoracic and lumbar curves cross the
midline. Both curves are structural, and the lumbar curve may be larger or less
flexible than the thoracic curve
• Type 2: S-shaped curve in which the thoracic curve is larger or less flexible than the
lumbar curve (also called a “false” double major curve)
• Type 3: Single thoracic curve without a structural lumbar curve
• Type 4: Long thoracic curve in which L5 is centered over the sacrum and L4 is
tilted into the thoracic curve
• Type 5: Double thoracic curve with T1 tilted into the convexity of the upper curve
Scoliosis
• two-dimensional classification system, published in 2001
• included the sagittal plane as well
• PT,MT,TL/L curves are measured using the Cobb
technique.
• The larger of the latter two is considered the major curve.
• Lesser curves are termed minor and are considered
structural :
- if they remain at least 25 on side-bending films
or
- Hyperkyphosis in the PT region (T2–T5>20) or TL(T10–
L2>20) ,regardless of their sidebending measurement.
• PT curves are always minor
• 42 curve patterns
• The type 1 (single thoracic) curve is the most
common
The general principle :
• major curve and structural minor curves should be
fused
• nonstructural minor curves may be allowed to
correct spontaneously following fusion of the
structural curves.
2:39 PM
Scoliosis
LIPPMAN - COBB’S classification
GROUP ANGLE OF CURVATURE
I <20
II 21-30
III 31-50
IV 51-75
V 75-100
VI 101-125
VII >125
Cobbs pitfall
• diurnal variation of 5°
• difficult to position the patient
• intraobserver variation by 5°–10° in Cobb angle
• Center of each end vertebra and
the apical segment are joined, and
their intersecting acute angle is
measured.
Risser -Ferguson systems
SCOLIOTIC INDEX
• Each vertebra (a–g) is considered
an integral part of the curve.
• A vertical spinal line (xy) is first
drawn whose endpoints are the
centres of the upper and lower end-
vertebrae of the curve.
• Lines are then drawn from the
centre of each vertebral body
perpendicular to the vertical
spinal line (aa', bb', … gg').
• Represent the linear
deviation of each vertebra
• Sum of vertebral body
lines, divided by the length
of the vertical line (xy)
gives the scoliotic index
DEGREEOFROTATION
• Rotation – reflects the degree of structural
change & resistance to correction of the scoliotic
curve
2 methods are used-
• Moe pedicle method
• Cobb spinous-process method.
2:39 PM
NASH AND MOE
COBB SPINOUS-PROCESS METHOD
• Migration towards the convexity of the curve
marks the degree of rotation.
DETERMINING MATURATION
• Secondary sex characteristics
• Excursion of iliac apophysis (Risser's staging)
• Ossification of the vertebral ring apophysis.
• Triradiate cartilage
• Bone age
RISSER’S
STAGING
•first appears laterally
near the ASIS and
progresses medially
toward completion at the
PSIS (capping)
•Boys -16yrs; Girls 14yrs
•grade 4 in F and
grade 5 in M usually
signals the end of curve
progression
Vertebral Ring Epiphyses
• closely parallels the maturation of spinal growth.
• most accurate indicator of completed spinal
growth
• strong inhibiting factor to future scoliotic
progression.
TRIRADIATE CARTILAGE
• Y- shaped epiphyseal plate
that occurs at the junction
where the ischium, ilium and
pubis meet in the skeletally
immature skeleton
• Closure or fusion -
15 - 16 years in males
13 - 14 years in females
• beginning at the acetabulum
and finishing at the greater
sciatic notch between ilium
and ischium.
Assessment of Vertebral Alignment and
Balance
• The plumb line: vertical
line drawn downward from
the center of the C7
vertebral body, parallel to
the lateral edges of the
radiograph
• CSVL : vertical line that is
drawn perpendicular to an
imaginary tangential line
drawn across the top of the
iliac crests on radiographs.
It bisects the sacrum.
CORONAL BALANCE
• evaluated by measuring
the distance between the
CSVL and the plumb
line
• greater than 2 cm
is abnormal
SAGITTAL BALANCE
• evaluated by measuring
the distance between the
posterosuperior
aspect of the S1
vertebral body and
the plumb line
The Probability of Progression
• curve progression parallels spinal growth.
• progresses only during growth
• ceases when skeletal maturity is reached (final
curvature is not severe)
• > 50 degree -more Morbidity mortality
(cardiopulmonary complications)
2:39 PM
• less than 30°: tends not to progress
• After the cessation of spinal growth, only curves
with a Cobb angle greater than 30° -
monitored for progression
• Lumbar and thoracolumbar curves are more
likely to progress than thoracic curves because
they lack the inherent stability provided by the
rib cage.
• Congenital scoliosis progresses in 75% of cases
• Idiopathic Infantile rarely progress
• Idiopathic Juvenile progress 75-80%
• Idiopathic Adolescent progress only 5%
• The factors that have the greatest effect on
scoliosis are spinal growth velocity and
magnitude of the curve at initial presentation
TREATMENT
Dr.Lewis Sayre
Scoliosis
Infantile idiopathic scoliosis
• Resolving curves:
-observed -serial physical examinations and
radiographic monitoring.
-Sleeping in the prone position- recommended
• Progressive curves –
treated with serial casting followed by orthotic
treatment
Treatment options for progressive
curves
• Serial casting + bracing+ later fusion
• Preoperative traction + later fusion
• Growing rod or vertical expandable prosthetic
titanium rib( VEPTR) instrumentation without
fusion
• Best results if casting started < 20 months of
age and<60 degree curves
• Cast change every 2-4 months
• Once corrected to < 10degrees -use custom
moulded brace
Operative treatment
• Indicated if curve is severe or increases despite
use of an orthosis/casting
• Principle of surgery- surgery should not only
stop progression of the curve but also allow
continued growth and development of the thorax
and lungs
• Fusionless instrumentation techniques are
preferred(VEPTR)
• Posterior spinal instrumentation and fusion are not
recommended due to:
– restriction of thoracic cage and lung development
– the risk of crankshaft phenomenon
(persistent anterior spinal growth in the presence of a
posterior fusion, leading to recurrent and increasing spinal
deformity).
• Growing rods may be used to control curve progression and
still allow for growth of the spine .
• Requires surgery every 6 months to lengthen the rods
• The use of magnetically controlled growing rods , such as
the MAGEC
Magnetically controlled
growing rod
•magnetic technology with adjustable
growing rods and an external remote
controller
• spinal bracing and distraction system
•avoids a return to surgery every 6 months
CRANKSHAFT PHENOMENON
• With a solid posterior fusion, continued anterior growth of
the vertebral bodies causes the vertebral body and discs to bulge
laterally toward the convexity and to pivot on the posterior fusion
• causing loss of correction, increase in vertebral rotation, and
recurrence of the rib hump
• Combined fusion necessary- to prevent crankshaft phenomenon
Treatment of juvenile idiopathic scoliosis
• Orthotic treatment is initiated for curves in the 25° to 50°
range.
• Surgical treatment is considered when curve magnitude
exceeds 50°
• convex disc stapling - an option for fusionless
correction of scoliosis
Surgical options
• principle of surgery – posterior instrumentation that is
sequencially lengthened to allow longitudinal growth while still
attempting to control progressive spinal deformity.
• Growing rod-surgery is required every 6 months to lengthen
the construct
• Dual growing rod- effective in controlling severe spinal
deformities and allowing spinal growth
Guided growth and physeal stapling –
• Principle of surgery- interertebral stapling is used to
produce a tethering effect on the convex side of the spine.
• This will allow for continued growth on the concave side
of the spine deformity and gradual correction of the
deformity with growth
Adolescent idiopathic scoliosis
Nonoperative treatment-
1.observation- young patient with mild curve <20
2.orthotic treatment-
• progression of curve beyond 25
• Curve of 30-40 in skeletally immature
SRS optimal inclusion criteria for bracing:
• Age 10yrs or older
• Risser grade 0-2
• Primary curve angle 25-40
• No prior treatment
3.Underarm cast
Orthosis (Bracing)
• to prevent curve progression
• Successful brace treatment is the initial correction achieved
by 50% or more upon initiation of bracing
• braces are applied when a curve is progressing and is
between 20 deg and 40 deg.
• rarely does a brace work after a curve is 40 deg or greater
Contraindications of
brace treatment :
• Skeletally mature patients
• Curves greater than 40°
• Thoracic lordosis (bracing potentiates
cardiopulmonary restriction)
• Patients unable to cope emotionally
with treatment
Type of Braces
• CTLSO (Milwaukee
brace). Used less
commonly due to its
cosmetic appearance.
However, for curves with
an apex above T8, it
remains most efficacious
• TLSO (e.g. Boston
brace). These lower-
profile orthoses are
better accepted by
patients and are
indicated for curves with
an apex at T8 or below
• Bending brace (e.g. Charleston brace).
- holds the patient is an acutely bent position in a direction
opposite to the curve apex. It is worn only during sleep.
• Flexible brace (e.g. SpineCor brace)
HALO-TRACTION DEVICE:
• A spinal skeletal traction and fixation device
• attached to the skull and is connected to a plaster body cast
by an adjustable steel frame.
• especially valuable in scoliosis when cardiopulmonary
insufficiency contraindicates the use of corrective cast.
• used with distal traction through pins inserted in the distal
femurs or proximal tibias , permitting the use of
respiratory aids and surgery while in traction.
Scoliosis
Prognosis-
• Factors :
– Curve magnitude : more angulation & rotation,
progress more (>20)
– Age : younger, progress more (<12yo)
– Risser’s score : score 0-1, progress more
– Curve length : shorter curves, progress more
– Location : higher curves, progress more
– Flexibility : stiffer curves, progress more
Operative /Surgery
Objective :
• obtain a solid fusion and to have the top and the bottom of
the fusion balanced within the stable zone.
Indications for surgery :
• <30 failed conservative treatment
• 30 - 45, with progression
• >30 with cosmetically unaccepted in skeletal maturity
• Increasing curve in growing child
• asymmetry of trunk in adolescent
• Pain uncontrolled by nonoperative treatment
• Thoracic lordosis
• Significant cosmetic deformity
Goals :
• Halting progression
• Achieve correction
• Achieve spinal balance
Objectives :
• Reduce rotational deformity & lateral deviation
• Athrodese the primary curve
• pulmonary function tests preoperatively on all
patients.
• cardiopulmonary compromise present -
posterior fusion is preferred over an anterior
approach to avoid pulmonary insult of a
thoracotomy
• clinical appearance of shoulder height and
symmetry is important in the selection of fusion
levels.
Types :
• Posterior approach
• Anterior approach
• Combined posterior &
anterior approach
• Video-assisted Thoracoscopic Surgery (VATS)
Posterior surgeries:
-Posterior spinal instrumentation-
• pedicle hook implantation
• sublaminar wires and cables
• Pedicle fixation- lumbar pedicle screw
-thoracic pedicle screw
-Facet fusion- Moe/Hall technique
Harrington rod Instrumentation
Luque trolley:
• uses wires to facilitate spine growth
• the wires slide along contoured rods.
Shilla procedure:
• spinal fusion at the most severe portion of the
scoliotic curve; termed the apex.
• anchor points at the top and bottom of the curve.
• The screws at the ends of the spine are specially
designed to allow movement and growth along the rod
SHILLA
LUQUE
Anterior surgeries
• Disc excision
• Anterior thoracoplasty
• Video assisted thoracoscopy
(VAT)
= screw insertion
= discectomy
= CD horizon eclipse spinal insrumentation
C-Arm Fluoroscopic View of
Vertebral Screw Insertion
• Vertebral Body Tethering:
Fusionless Pediatric Scoliosis Correction
Segmental PEDICLE SCREW construct
CD HORIZON® Legacy™
Spinal System
• by Dr. Lenke
• The Legacy System is a complete and comprehensive
system of a variety of implantable devices, including rods,
hooks, screws, and other instrumentation
• Comprehensive three-dimensional (3D) correction of
the spinal deformity.
CASES WITH XRAYS
1
• Adolescent Idiopathic scoliosis with progression
of the curve
• AIS with Lenke Type 3B- main curve (T6-
T11) 72 degrees.
• Failure to control curve inspite of bracing
• Patient not satisfied with the body perception
Scoliosis
2
Pre op
Post op
Scoliosis
THANK
YOU
REFERENCES :
• Rothman- The spine
• Tachdjian Pediatric Orthopaedics
• Gopalan’s evidence based orthopaedcis
principles
• Campbell’s operative orthopaedics
• Rockwood and Green’s fractures in adults
• www.srs.org ( Spine Research Society)
Scoliosis
• Posterior segmental spinal instrumentation
and fusion are indicated in type 1 curves with a
normal or hyperkyphotic sagittal profile and in
patients with diminished pulmonary function
• Instrumented posterior spinal fusion from the
neutral vertebra above to the stable vertebra below
(or stable minus one or two levels as defined below)
is the traditional treatment
• type 1 MT curves can be fused to the ‘‘stable minus
one’’ vertebra.
• Anterior spinal fusion may be selected in type 1 curves,
particularly when there is hypokyphosis or a ‘‘C’’
lumbar modifier. Anterior fusion may be preferred in a
patient who is skeletally immature to minimize the risk
for crankshaft phenomenon from subsequent growth.
• Because anterior fusion tends to increase
kyphosis, whereas posterior fusion tends to
decrease it, anterior fusion may not be suitable in
patients with preoperative high normal or hyperkyphosis
• use of segmental thoracic pedicle screw fixation
increased instrumented curve correction, improved
spontaneous lumbar compensatory curve correction, and
improved thoracic torsion and rotation
• With hook constructs, it has been recommended that the
distal level be the “stable” vertebra, the one that is
intersected or bisected by the center sacral line
• the appropriate level to fix proximally is determined by
the sagittal plane as well. In the sagittal plane, the top
and the bottom of the fusion should be transitional, in an
area of relative lordosis
• Established teaching was that posterior fusion should
stop two levels above and one level below the
transitional segments
• Those levels can at times be shortened if fixation is
achieved at every level with hooks or pedicle screws and
if the “saving of levels” is compatible with the sagittal
plane
• LIV should achieve horizontalization,
centralization, and stabilization
Prox fusion – acc to shoulders
Higher shoulder fusion level prox
• Left T2
• Level T3/4
• Right T4/5
Scoliosis

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Scoliosis

  • 1. MODERATOR – Dr.Nandish PRESENTER – Dr.Venkatesh Singh
  • 2. DEFINITION • “Scoliosis” - Greek word meaning “crooked.” • Scoliosis is defined as lateral deviation of the normal vertical line of the spine, which when measured on a radiograph, is greater than 10 degrees ,with associated rotation of vertebrae • Patients with curves less than 10 degrees are considered to have spinal asymmetry 2:39 PM
  • 4. • The lateral curvature of the spine is associated with rotation of the vertebrae within the curve- • a three-dimensional deformity occurs in three planes: (1) lateral intervertebral tilting in the frontal plane (2) a rotatory component in the axial plane (3) intervertebral extension in the sagittal plane leading to lordosis of the scoliotic segment
  • 5. • The common right (dextro) thoracic curve, (measuring 10°) - considered physiologic - to accommodate the size and position of the heart, lung, and aorta or to be related to handedness. • 7 times more prevalent in females • 80% of scoliosis origin unknown
  • 7. Classification  Structural ( radiographically Cobb angle of 25° or more on ipsilateral side-bending radiographic views)  Non-structural - compensatory and postural
  • 8. Based on aetiology : • Idiopathic • Congenital • Neuromuscular • Syndromic AGE-BASED: (idiopathic)  infantile(birth and 3 years)  juvenile (3 and 10 years of age)  adolescent (10- skeletal maturity) MC
  • 12. NON STRUCTURAL • A reversible lateral 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 . 2:39 PM
  • 13. Correction of the lateral curve is possible by: -Forward or side bending -Positional changes and alignment of the pelvis or spine. -Muscle contraction -By correction of a leg-length discrepancy
  • 14. Etiology of Nonstructural scoliosis- • Leg length discrepancy: (structural or functional) Measurable difference because of a dislocated hip, asymmetric leg or foot postures. • Habitual asymmetric posture: Sitting with weight shifted onto one hip or standing with weight primarily supported on one leg • Muscle guarding or spasm from a painful stimuli in the back or neck
  • 16. CONGENITAL SCOLIOSIS • Congenital scoliosis is a progressive three- dimensional deformity of the spine caused by congenital anomalies of the vertebrae that result in an imbalance of the longitudinal growth of the spine. • the familial incidence = 1% to 5% • more common in girls (3 : 2)
  • 17. DEVELOPMENT OF SPINE • Paraxial mesoderm on either side of the notochord -form somites ( Somitogenesis) Each somite subdivides further into ventral sclerotome and dorsolateral dermomyotome. • 4th week of development- cells from the sclerotome on each side of the body migrate ventrally and surround the notochord • Each vertebra is formed by sclerotome cells from two somite levels . • The ventral part of each vertebra forms the body around the notochord, and the dorsal part forms costal processes laterally and the vertebra arch dorsally.
  • 18. • 6th week of development- mesenchymal cells fill the space between two vertebral bodies to contribute to formation of the intervertebral structures. This stage is called Segmentation stage.
  • 21. • Anomalies occur in 30% to 60% • MC -the spinal cord and the genitourinary tract. • Intraspinal anomalies include - tethered cord, diastematomyelia, and syringomyelia. • The most common genitourinary defects are renal agenesis, ectopic kidney, duplication, and reflux. • VACTERL association : Vertebral defects (V), Anal atresia (A), Cardiac defect (C), Tracheoesophageal fistula (TE), Radial limb reduction, and Renal defects (R) and Limb defect (L) • in Klippel-Feil syndrome, Marfan syndrome, Ehlers- Danlos syndrome, Charcot-Marie-Tooth disease.
  • 22. HUETER-VOLKMAN PRINCIPLE •Hueter-Volkmannn Law:bone growth in the period of skeletal immaturity is retarded by mechanical compression on the growth plate and accelerated by growth plate tension
  • 23. • the rotation of vertebral bodies in the axial plane • causes discrepant axial loading between the ventrally and dorsally located portions of the involved vertebrae • ventrally located part of the vertebral column becomes the concave side • the dorsally located part becomes the convex side of a lateral curve
  • 24. NEUROMUSCULAR SCOLIOSIS • The second most common form of scoliosis and is associated with disorders of the nerve or muscular systems, such as: a)Neuropathic - • 1)Lower motor neuron(e,g.poliomyelitis) • 2)Upper motor neuron(e,g. cerebral palsy) b)Myopathic - 1)Progressive(e,g. muscular dystrophy) 2)Static(e,g. Amyotonia congenita) 3)others(e,g.Friedreich’s ataxia, unilateral amelia)
  • 25. • These cause muscles to become weak, spastic or paralyzed — and unable to support the spine, resulting in spinal curvatures. • Treatment will depend on child's age and underlying condition, as well as the type and severity of the spinal curve.
  • 26. IDIOPATHIC SCOLIOSIS • Idiopathic scoliosis is the most common type of scoliosis. • defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine in the absence of any known cause • Idiopathic scoliosis is divided into three categories based on chronologic age: -infantile (birth to 2 years+ 11 months) -juvenile(3 years to 9 years+11 months), -adolescent (10 years to 17 years+11 months) 2:39 PM
  • 27. INFANTILE IDIOPATHIC SCOLIOSIS • Common in Europe • Male predominance • Left thoracic curve pattern is most common • Two types have been identified: a resolving type (85%) and a progressive type (15%)
  • 28. • curves that can progress can be obtained from the rib-vertebral angle difference (RVAD) and “phase of the rib head.” • If the head and neck of the convex rib of the vertebral body at the apex of the curve does not overlap the vertebral body, it is termed phase I • if it does overlap, it is termed phase II. • Curves with RVAD greater than 20 degrees or phase II angles are very likely to progress 2:39 PM
  • 30. JUVENILE SCOLIOSIS • 12%–16% of all patients with idiopathic scoliosis • Increasing female predominance • Most common curve patterns are right thoracic • Approximately 70% of curves progress
  • 31. ADOLESCENT SCOLIOSIS • most common type of scoliosis in children • A female predominance • Thoracic curve patterns are generally convex to the right • Idiopathic scoliosis in adolescence is not typically associated with severe pain
  • 32. CLINICAL FEATURES • Deformity is usually the presenting symptom • Pain • Rib hump or abnormal para spinal muscular prominence (indicates spinal rotation) (Rib hump leads to asymmetry of trunk called angle trunk rotation (ATR) )
  • 33. • Raised shoulders(thoracic curves-convex side) (Lumbar curves – concave side) • Scapula – rotated outwards and forwards with elevation on convex side • Increased flank creases – concave side • Higher ASIS PSIS – concave side 2:39 PM
  • 34. Physiological Effects of Scoliosis • Mid-back pain • lower back pain, • neck pain, headaches, • premature disc and joint degeneration • Decreased pulmonary function
  • 38. Patient history • Age at onset • Evidence of maturation • Back pain • complete neurological history • Family history • Self-perception
  • 39. Physical examination • Height measurement • Gait check • Foot shape • Skin inspection • Assessment of pubertal development • Neurological examination ( including motor, sensory and reflex tests ) • Symmetry of shoulders and iliac crest 2:39 PM
  • 40. Assessment of scoliosis • the four basic spinal parameters evaluated in scoliosis are  curvature  rotation  flexibility  skeletal maturation
  • 41. SCOLIOMETRY The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve.
  • 42. ` • Plumb line - On posterior aspect, line drawn from occiput should normally align with gluteal cleft
  • 44. • Simple curve-Single spinal deviation • Compound curve- Displacements in Right & Left direction • Primary curve- Curve that develops first • Secondary or Compensatory curve- Develops as a balancing response to the primary curve
  • 45. • Non structural curve- Curve is flexible and corrects by bending towards convex side
  • 46. STRUCTURAL SCOLIOSIS • Non correctable deformity of affected spinal segment. • Vertebral rotation is an essential component • Spinous process swing round towards the concavity of the curve. • Transverse processes on the convexity rotates posteriorly.
  • 47. • To determine the severity of the curve • X-ray Antero Posterior, Lateral & Oblique view of spine • Right & left bending view – determine the degree of flexibility of spine & to see how much curve can be passively corrected
  • 48. THORACIC curve – STRUCTURAL LUMBAR curve – COMPENSATORY 2:39 PM
  • 49. •The end vertebrae (E) -are most tilted •Apical vertebra(A)- is the central vertebra within a curve. It is typically the least tilted, most rotated, and most horizontally displaced vertebra within a curve •A neutral vertebra (N) - one that is not rotated •a stable vertebra (S)- is one that is bisected or nearly bisected by the CSVL (dotted line)
  • 51. CURVATURE MEASUREMENT • COBB- LIPPMANN : • most accepted • AP radiograph entire spine • a line is drawn along the superior border of the cephalad end vertebra and inferior surface of the caudad end vertebra • Perpendicular lines are erected from each endplate line, and the vertical (not horizontal) angle formed by their intersection is measured 2:39 PM
  • 53. Double curve • One vertebra is upper end vertebra for lower curve and lower end vertebra for upper curve (transitional vertebra). • Only one line drawn on this vertebra.
  • 54. King-Moe classification • Published in 1983 • thoracic curve patterns • five curve types as a guide to surgical treatment • The King classification does not address lumbar curves, thoracolumbar curves, or triple major curves. • It does not evaluate sagittal plane alignment.
  • 55. • Type 1: S-shaped curve in which both the thoracic and lumbar curves cross the midline. Both curves are structural, and the lumbar curve may be larger or less flexible than the thoracic curve • Type 2: S-shaped curve in which the thoracic curve is larger or less flexible than the lumbar curve (also called a “false” double major curve) • Type 3: Single thoracic curve without a structural lumbar curve • Type 4: Long thoracic curve in which L5 is centered over the sacrum and L4 is tilted into the thoracic curve • Type 5: Double thoracic curve with T1 tilted into the convexity of the upper curve
  • 57. • two-dimensional classification system, published in 2001 • included the sagittal plane as well • PT,MT,TL/L curves are measured using the Cobb technique. • The larger of the latter two is considered the major curve. • Lesser curves are termed minor and are considered structural : - if they remain at least 25 on side-bending films or - Hyperkyphosis in the PT region (T2–T5>20) or TL(T10– L2>20) ,regardless of their sidebending measurement.
  • 58. • PT curves are always minor • 42 curve patterns • The type 1 (single thoracic) curve is the most common The general principle : • major curve and structural minor curves should be fused • nonstructural minor curves may be allowed to correct spontaneously following fusion of the structural curves. 2:39 PM
  • 60. LIPPMAN - COBB’S classification GROUP ANGLE OF CURVATURE I <20 II 21-30 III 31-50 IV 51-75 V 75-100 VI 101-125 VII >125
  • 61. Cobbs pitfall • diurnal variation of 5° • difficult to position the patient • intraobserver variation by 5°–10° in Cobb angle
  • 62. • Center of each end vertebra and the apical segment are joined, and their intersecting acute angle is measured. Risser -Ferguson systems
  • 63. SCOLIOTIC INDEX • Each vertebra (a–g) is considered an integral part of the curve. • A vertical spinal line (xy) is first drawn whose endpoints are the centres of the upper and lower end- vertebrae of the curve. • Lines are then drawn from the centre of each vertebral body perpendicular to the vertical spinal line (aa', bb', … gg').
  • 64. • Represent the linear deviation of each vertebra • Sum of vertebral body lines, divided by the length of the vertical line (xy) gives the scoliotic index
  • 65. DEGREEOFROTATION • Rotation – reflects the degree of structural change & resistance to correction of the scoliotic curve 2 methods are used- • Moe pedicle method • Cobb spinous-process method. 2:39 PM
  • 67. COBB SPINOUS-PROCESS METHOD • Migration towards the convexity of the curve marks the degree of rotation.
  • 68. DETERMINING MATURATION • Secondary sex characteristics • Excursion of iliac apophysis (Risser's staging) • Ossification of the vertebral ring apophysis. • Triradiate cartilage • Bone age
  • 69. RISSER’S STAGING •first appears laterally near the ASIS and progresses medially toward completion at the PSIS (capping) •Boys -16yrs; Girls 14yrs •grade 4 in F and grade 5 in M usually signals the end of curve progression
  • 70. Vertebral Ring Epiphyses • closely parallels the maturation of spinal growth. • most accurate indicator of completed spinal growth • strong inhibiting factor to future scoliotic progression.
  • 71. TRIRADIATE CARTILAGE • Y- shaped epiphyseal plate that occurs at the junction where the ischium, ilium and pubis meet in the skeletally immature skeleton • Closure or fusion - 15 - 16 years in males 13 - 14 years in females • beginning at the acetabulum and finishing at the greater sciatic notch between ilium and ischium.
  • 72. Assessment of Vertebral Alignment and Balance • The plumb line: vertical line drawn downward from the center of the C7 vertebral body, parallel to the lateral edges of the radiograph • CSVL : vertical line that is drawn perpendicular to an imaginary tangential line drawn across the top of the iliac crests on radiographs. It bisects the sacrum.
  • 73. CORONAL BALANCE • evaluated by measuring the distance between the CSVL and the plumb line • greater than 2 cm is abnormal SAGITTAL BALANCE • evaluated by measuring the distance between the posterosuperior aspect of the S1 vertebral body and the plumb line
  • 74. The Probability of Progression • curve progression parallels spinal growth. • progresses only during growth • ceases when skeletal maturity is reached (final curvature is not severe) • > 50 degree -more Morbidity mortality (cardiopulmonary complications) 2:39 PM
  • 75. • less than 30°: tends not to progress • After the cessation of spinal growth, only curves with a Cobb angle greater than 30° - monitored for progression • Lumbar and thoracolumbar curves are more likely to progress than thoracic curves because they lack the inherent stability provided by the rib cage.
  • 76. • Congenital scoliosis progresses in 75% of cases • Idiopathic Infantile rarely progress • Idiopathic Juvenile progress 75-80% • Idiopathic Adolescent progress only 5% • The factors that have the greatest effect on scoliosis are spinal growth velocity and magnitude of the curve at initial presentation
  • 79. Infantile idiopathic scoliosis • Resolving curves: -observed -serial physical examinations and radiographic monitoring. -Sleeping in the prone position- recommended • Progressive curves – treated with serial casting followed by orthotic treatment
  • 80. Treatment options for progressive curves • Serial casting + bracing+ later fusion • Preoperative traction + later fusion • Growing rod or vertical expandable prosthetic titanium rib( VEPTR) instrumentation without fusion
  • 81. • Best results if casting started < 20 months of age and<60 degree curves • Cast change every 2-4 months • Once corrected to < 10degrees -use custom moulded brace
  • 82. Operative treatment • Indicated if curve is severe or increases despite use of an orthosis/casting • Principle of surgery- surgery should not only stop progression of the curve but also allow continued growth and development of the thorax and lungs • Fusionless instrumentation techniques are preferred(VEPTR)
  • 83. • Posterior spinal instrumentation and fusion are not recommended due to: – restriction of thoracic cage and lung development – the risk of crankshaft phenomenon (persistent anterior spinal growth in the presence of a posterior fusion, leading to recurrent and increasing spinal deformity). • Growing rods may be used to control curve progression and still allow for growth of the spine . • Requires surgery every 6 months to lengthen the rods • The use of magnetically controlled growing rods , such as the MAGEC
  • 84. Magnetically controlled growing rod •magnetic technology with adjustable growing rods and an external remote controller • spinal bracing and distraction system •avoids a return to surgery every 6 months
  • 85. CRANKSHAFT PHENOMENON • With a solid posterior fusion, continued anterior growth of the vertebral bodies causes the vertebral body and discs to bulge laterally toward the convexity and to pivot on the posterior fusion • causing loss of correction, increase in vertebral rotation, and recurrence of the rib hump • Combined fusion necessary- to prevent crankshaft phenomenon
  • 86. Treatment of juvenile idiopathic scoliosis • Orthotic treatment is initiated for curves in the 25° to 50° range. • Surgical treatment is considered when curve magnitude exceeds 50° • convex disc stapling - an option for fusionless correction of scoliosis
  • 87. Surgical options • principle of surgery – posterior instrumentation that is sequencially lengthened to allow longitudinal growth while still attempting to control progressive spinal deformity. • Growing rod-surgery is required every 6 months to lengthen the construct • Dual growing rod- effective in controlling severe spinal deformities and allowing spinal growth
  • 88. Guided growth and physeal stapling – • Principle of surgery- interertebral stapling is used to produce a tethering effect on the convex side of the spine. • This will allow for continued growth on the concave side of the spine deformity and gradual correction of the deformity with growth
  • 89. Adolescent idiopathic scoliosis Nonoperative treatment- 1.observation- young patient with mild curve <20 2.orthotic treatment- • progression of curve beyond 25 • Curve of 30-40 in skeletally immature SRS optimal inclusion criteria for bracing: • Age 10yrs or older • Risser grade 0-2 • Primary curve angle 25-40 • No prior treatment 3.Underarm cast
  • 90. Orthosis (Bracing) • to prevent curve progression • Successful brace treatment is the initial correction achieved by 50% or more upon initiation of bracing • braces are applied when a curve is progressing and is between 20 deg and 40 deg. • rarely does a brace work after a curve is 40 deg or greater
  • 91. Contraindications of brace treatment : • Skeletally mature patients • Curves greater than 40° • Thoracic lordosis (bracing potentiates cardiopulmonary restriction) • Patients unable to cope emotionally with treatment
  • 92. Type of Braces • CTLSO (Milwaukee brace). Used less commonly due to its cosmetic appearance. However, for curves with an apex above T8, it remains most efficacious • TLSO (e.g. Boston brace). These lower- profile orthoses are better accepted by patients and are indicated for curves with an apex at T8 or below
  • 93. • Bending brace (e.g. Charleston brace). - holds the patient is an acutely bent position in a direction opposite to the curve apex. It is worn only during sleep. • Flexible brace (e.g. SpineCor brace)
  • 94. HALO-TRACTION DEVICE: • A spinal skeletal traction and fixation device • attached to the skull and is connected to a plaster body cast by an adjustable steel frame. • especially valuable in scoliosis when cardiopulmonary insufficiency contraindicates the use of corrective cast. • used with distal traction through pins inserted in the distal femurs or proximal tibias , permitting the use of respiratory aids and surgery while in traction.
  • 96. Prognosis- • Factors : – Curve magnitude : more angulation & rotation, progress more (>20) – Age : younger, progress more (<12yo) – Risser’s score : score 0-1, progress more – Curve length : shorter curves, progress more – Location : higher curves, progress more – Flexibility : stiffer curves, progress more
  • 97. Operative /Surgery Objective : • obtain a solid fusion and to have the top and the bottom of the fusion balanced within the stable zone. Indications for surgery : • <30 failed conservative treatment • 30 - 45, with progression • >30 with cosmetically unaccepted in skeletal maturity • Increasing curve in growing child • asymmetry of trunk in adolescent • Pain uncontrolled by nonoperative treatment • Thoracic lordosis • Significant cosmetic deformity
  • 98. Goals : • Halting progression • Achieve correction • Achieve spinal balance Objectives : • Reduce rotational deformity & lateral deviation • Athrodese the primary curve
  • 99. • pulmonary function tests preoperatively on all patients. • cardiopulmonary compromise present - posterior fusion is preferred over an anterior approach to avoid pulmonary insult of a thoracotomy • clinical appearance of shoulder height and symmetry is important in the selection of fusion levels.
  • 100. Types : • Posterior approach • Anterior approach • Combined posterior & anterior approach • Video-assisted Thoracoscopic Surgery (VATS)
  • 101. Posterior surgeries: -Posterior spinal instrumentation- • pedicle hook implantation • sublaminar wires and cables • Pedicle fixation- lumbar pedicle screw -thoracic pedicle screw -Facet fusion- Moe/Hall technique
  • 103. Luque trolley: • uses wires to facilitate spine growth • the wires slide along contoured rods. Shilla procedure: • spinal fusion at the most severe portion of the scoliotic curve; termed the apex. • anchor points at the top and bottom of the curve. • The screws at the ends of the spine are specially designed to allow movement and growth along the rod
  • 105. Anterior surgeries • Disc excision • Anterior thoracoplasty • Video assisted thoracoscopy (VAT) = screw insertion = discectomy = CD horizon eclipse spinal insrumentation C-Arm Fluoroscopic View of Vertebral Screw Insertion
  • 106. • Vertebral Body Tethering: Fusionless Pediatric Scoliosis Correction
  • 108. CD HORIZON® Legacy™ Spinal System • by Dr. Lenke • The Legacy System is a complete and comprehensive system of a variety of implantable devices, including rods, hooks, screws, and other instrumentation • Comprehensive three-dimensional (3D) correction of the spinal deformity.
  • 110. • Adolescent Idiopathic scoliosis with progression of the curve • AIS with Lenke Type 3B- main curve (T6- T11) 72 degrees. • Failure to control curve inspite of bracing • Patient not satisfied with the body perception
  • 116. REFERENCES : • Rothman- The spine • Tachdjian Pediatric Orthopaedics • Gopalan’s evidence based orthopaedcis principles • Campbell’s operative orthopaedics • Rockwood and Green’s fractures in adults • www.srs.org ( Spine Research Society)
  • 118. • Posterior segmental spinal instrumentation and fusion are indicated in type 1 curves with a normal or hyperkyphotic sagittal profile and in patients with diminished pulmonary function • Instrumented posterior spinal fusion from the neutral vertebra above to the stable vertebra below (or stable minus one or two levels as defined below) is the traditional treatment • type 1 MT curves can be fused to the ‘‘stable minus one’’ vertebra.
  • 119. • Anterior spinal fusion may be selected in type 1 curves, particularly when there is hypokyphosis or a ‘‘C’’ lumbar modifier. Anterior fusion may be preferred in a patient who is skeletally immature to minimize the risk for crankshaft phenomenon from subsequent growth. • Because anterior fusion tends to increase kyphosis, whereas posterior fusion tends to decrease it, anterior fusion may not be suitable in patients with preoperative high normal or hyperkyphosis • use of segmental thoracic pedicle screw fixation increased instrumented curve correction, improved spontaneous lumbar compensatory curve correction, and improved thoracic torsion and rotation
  • 120. • With hook constructs, it has been recommended that the distal level be the “stable” vertebra, the one that is intersected or bisected by the center sacral line • the appropriate level to fix proximally is determined by the sagittal plane as well. In the sagittal plane, the top and the bottom of the fusion should be transitional, in an area of relative lordosis • Established teaching was that posterior fusion should stop two levels above and one level below the transitional segments • Those levels can at times be shortened if fixation is achieved at every level with hooks or pedicle screws and if the “saving of levels” is compatible with the sagittal plane
  • 121. • LIV should achieve horizontalization, centralization, and stabilization
  • 122. Prox fusion – acc to shoulders Higher shoulder fusion level prox • Left T2 • Level T3/4 • Right T4/5