Chapter 140 - Pediatric Spine Flashcards
normal thoracic kyphosis
20-45 degrees
normal lumbar lordosis
30-60
Growth velocity of the T1-L5 segment is fastest when?
the first 5 years of life
male:female ratio in IIS scoli
1:1
most common curve in INFANTILE IDIOPATHIC SCOLIOSIS
LEFT THORACIC
most important measure progression in IIS
apical rib-vertebral angle difference >20
or
overlap of the rib head with the apical vertebra
Juvenile IS male:female
female>male
most common curve in JUVENILE IDIOPATHIC SCOLI
RIGHT THORACIC
what percentage of JIS cases progress?
95% of cases
when to get an MRI for scoli
IIS - 22%have neural axis abnormality
JIS - 25% have neural axis abnormality
AIS - if left thoracic curve
short angular curves, absence of apical thoracic lordosis, absence of rotation, congenital scoli, hyperkyphosis
male to female ratio in AIS
in curves <30, 1:1 female to male
in curves >30, 10:1 female to male
who is at greatest risk of progression in AIS
girls
pre-menarchal
risser grade 0
tanner stage <3
open triradiate cartilage
what finding is commonly associated with non-rotational scoli curves and asymmetric abdominal reflexes?
syrinx
casting for infantile idiopathic scoli
can be curative for kids <18-24 months, and with a curve of <40-50deg
derotational casts applied in the OR and changed every 2-4 months for a total perior of 1year followed by bracing
IIS indications for bracing
RVAD >20, phase 2 rib-vertebra relationship, cobb >30degrees
curves <20degrees spontaneously resolve in the majority of patients
indications for bracing JIS and AIS
JIS: curves >20
AIS: curves >25 (risser 0,1,2 - bracing is ineffective after that)
tlso is most effective when apex vertebra is at what level?
T7 or distal
surgical indications for IIS and JIS
curves >50-70
surgical indication for AIS
thoracic curve >50
lumbar curve >45
marked trunk imbalance with curve >40
what is the effect of an incarcerated vertebra on the spine with regards to scoli progression
- no scoli develops - deficiencies above and below compensate
failures of formation in congenital scoli
wedge vertebra - mildest form
hemivertebrae
- can be
fully segmented - disk space present above nd below a hemivertebra
semisegmented - hemivertebra fused to a normal vertebra with disc on the other side
incarcerated - no scoli
nonsegmented - hemivertebra fused to vertebrae on both sides
failures of segmentation in congenital scoli
block vertebra - best prognosis
- bilateral bony bars
unilateral bar - bar is on concave side of scoli
unilateral bar, contralateral hemivertebrae - worst prognosis for progression (5-10deg/yr)
workup of patients with congenital scoli should include what?
renal
cardiac evals
spinal axis MRI
treatment of unilateral bars
early in situ arthrodesis
treatment of fully segmented hemivertebrae
in kids <5, curve <40
- in situ contralateral hemiepiphysiodesis with ipsilateral hemiarthrodesis
in kids<6, curve <40 with marked trunk imbalance
- hemivertebra excision
why dont you brace neuromuscular scoli kids?
bracing is ineffective at preventing curve progression, can cause skin issues, can contribute to GI and pulmonary issues
indications for scoli fusion in DMD?
earlier treatment - curves 20-30 before pulm compromise becomes an issue
FVC <30% increases risk of prolonged post op mechanical ventilation
Scheuermann kyphosis
throacic hyperkyphosis with 3 consecutive vertebra with >5degree anterior vertebral wedging
Male:female 4-7:1
natural history of scheuermann kyphosis
back pain that only rarely interferes with ADLs, mean curvature 71deg
what degree of curvature for scoli and kyphosis causes pulm compromise
> 60 deg causes measurable pulm compromise, but >90 causes clinically significant for scoli
> 100 degrees kyphosis necessary for pulm compromise
radiographic features of scheuermann kyphosis
vertebral end plate anomalies
loss of disc height
schmorl nodes
wedge vertebra
need an MRI in all cases of congenital scoli
choosing fusion levels in kyphosis correction
limit correction to 50% of deformity to prevent proximal or distal junctional kyphosis, hardware pullout
end vertebra or one proximal to end vertebra should be the proximal level
lowest instrumented vertebra should be the sagittal stable vertebra
neurologic injury post correction is most common in what kind of scoli surgery?
kyphosis correction - thought to be vascular stretch injury
artery of adamkiewicz is where
left side t11 (anywhere from t8-l2)
spondylolysis
stress fracture thru pars interarticularis
spondylolisthesis
anterior slippage of the superior vertebra on the inferior vertebra
L5 most common
associated conditions in spondylolisthesis
hamstring tightness
paraspinal muscle spasm
nerve roots affected in spondylolisthesis
degenerative spondy (L4 on L5) -> traversing nerve root -> L5
isthmic spondy (L5 fracture -> L5 on S1) -> exiting nerve root 2/2 fracture callous -> L5
in down syndrom what is the most common cervical abnormality?
atlano-occipital hypermobility/instability
subaxial spine is not involved in down syndrome
occiput to C2 fusion should be performed when ADI>5mm +neuro sx, or ADI >10mm asx
Klippel feil syndrome
congenital cervical fusion
- basilar invagination
- short broad neck with a low hairline
1/3 will have sprengels deformity (high riding scapula)
Atlanto dens interval is used for diagnosing what condition?
atlanto axilal instabiilty
ADI>5mm = AAI (normal in adults is 2-3mm but in kids up to 5mm is normal)
Powers ratio is used for diagnosing what condition?
atlantoaxial instability
normal <1
atlantoaxial rotatory displacement
most common after a upper respiratory viral illness
can range from mild displacement to fixed subluxation of c1 on c2
treatment: NSAIDs and soft collar if low grade
if lasts >1 week:
- reducible - head halter traction
if lasts >1mo:
halo
C1-2 fusion if neuro sx or persistent deformity
Morquio syndrome is characterized by what spinal abnormalities?
atlantoaxial instability 2/2 odontoid hypoplasia
tx for morquio syndrome and SED >5mm instability regardless of sx
most common complication of anterior pin in halo traction
supraorbital nerve
kids get MORE pins (like 6-12) with less torque (<5lb-in)
most common nerve complication overall with halo traction
6th facial nerve palsy (abducens nerve) - unable to lateral gaze
pseudosubluxation is a common pedi cervical spine finding at what level?
C2-3, less commonly C3-4
must reduce on extension XR
subluxation does not exceed 1.5mm
difference in diagnosis adult and child discitis?
blood cultures before abx, but you do not need a ct biopsy in kids, just treat presumptively for staph with 7-10 days IV vanc then oral for several weeks
if not gettin better then do culture
cervical disc calcification
treatment is observation
resolves within 1 month
anterior spine lesions
langerhans cell histiocytosis -> vertebra plana
hemangioma (vertebral body vertical striations)
posterior element tumors
osteoid osteoma (Do not do radioablation in the spine 2/2 neuro risk)
osteoblastoma (surgery is always indicated)
aneurysmal bone cyst
