Chapter Nine: Orthoses for spinal deformity Flashcards
What are the most common scoliotic deformities said to benefit from spinal orthoses?
Idopathic scoliosis
Scheuermann’s kyphosis
What is scoliosis?
A lateral curvature of the spine, greater than 10 degrees as measured by the Cobb method.
What is the three-dimensional deformity that occurs with lateral curvature?
Coronal plane translation of a series of vertebrae away from midline
Transverse plane deformity by way of vertebral roatation in relation to each other because of the nature of the intervertebral arcticulation of the posterior curves
Anterior translation in the sagittal plane resulting in a hypokyphotic or lordotic relationship of the effected vertebrae
What is idiopathic scoliosis?
(IS) Unknown cause or etiology of the scoliotic deformity
What is the most common form of scoliosis?
Idiopathic scoliosis
What is infantile idiopathic scoliosis?
Scoliosis in patients less than 3 years of age.
What is juvenile idiopathic scoliosis?
Scoliosis detected in patients ages 3 to 10 years of age
What is adolescent idiopathic scoliosis?
Scoliosis detected in patients after 10 years, but before skeletal maturity .
What is adult scoliosis?
Scoliosis detected after skeletal maturity.
What are two other terms for scoliosis?
Early-onset idiopathic scoliosis (EIS)
Late-onset idiopathic scoliosis (LIS)
What is early-onset idiopathic scoliosis?
Onset of scoliosis prior to the age of 5
What is late-onset iodipathic scoliosis?
Onset of scoliosis after the age of 5
What side is the thoracic curve usually on in EIS? Which gender most commonly gets EIS?
Left side thoracic curve
Boys
Does EIS resolve without treatment
Occasionally it sponanteously resolves
What does RVAD stand for?
Rib-vertevra angle difference
What is the most reliable indicator for differentiating resolving from progressive scoliosis?
RVAD
What is RVAD?
The difference between the concave and convex side ribs in relation to the apical thoracic vertebra
The amount of apical vertebral rotation, as defined by phase I and phase II rotation
An RVAD of <20 degrees means what?
A high likelihood of curve resolution
An RVAD of 20 degrees or greater means what?
A high likelihood of curve progression.
A phase II relationship between the rib head and the apical vertebra on the convex side implies what?
That progression of the curve is almost certain.
What is a much more significant concern in those diagnosed with EIS compared to LIS? WHY?
Pulmonary compromise.
The presence of a potentially progressive chest wall deformity associated with the scoliosis during the time in which the lungs are rapidly developing
What results from pulmonary compromise in patient’s with EIS?
Restrictive pattern of lung disease that includes reductions in vital capacity and total lung capacity.
The amount of vital capactiy reduction is also influenced by the location and severity of the ccurve
They are also at a greater risk of respiratory failure at or before middle age
What is curve progression?
A measured difference of 5 degrees or greater however a 10 degree change has been reparoted as being required for 95% certainty that an observed changed was not caused by measurement error alone.
What is the goal of a scoliosis orthosis?
Prevent further progression of a curve that would otherwise worsen if left untreated.
What are the factors that influence whether a curve secrondary to AIS will progress?
Patient gender
Remaining growth
Curve magnitude
Curve pattern.
Which gender is most likely to experience curve progression?
Girls
What two maturity indicies are used to measure the amount of growth remaining?
The Risser sign
Girls: the onset of menstruation
What is the Risser sign?
A skeletal marker based on the ossification of the iliac apophysis. It is interpreted by viewing a standing posterior-anterior radiograph of the spine and pelvis, where ossification of the pelvis begins laterally and progresses medially until maturation.
What is the range on the Risser sign?
0-5
0 is no ossification
5 is full ossified ilium
A risser sign of 0, 1, or 2 means what?
Significant growth remaining
Significant growth remaining can mean what?
A greater risk for curve progression
What is a third way to determin skeletal maturity?
Peak height velocity
How is peak height velocity calculated?
Changes in patient’s height measurements over time.
It is typically measured in no less than 4 and no more than 6 month.
What is the average PHV for girls?
.8 cm per year
What is the average PHV for boys?
9.5 cm per year
What does PGA stand for?
Peak growth age
What had a stronger correlation between curve progression than age, Risser sing, or menarchal status?
PGA
What is an important threshold in determining progression?
30 degrees of the primary curve pluse the timing of PGA
A scoliosis curve of what, in an immature patient is typically considered for orthotic treatment?
25 degrees
What curves are the least likely to progress and are the most receptive to brace treatment?
Single lumbar and single thoracolumbar curves.
What curves are more likely to progress?
single thoracic
Double curves
What percent of curves progressed AFTER skeletal maturity?
68%
Progression of curves greater than 30 degreees are related to the amount of what?
Vertebral rotation
Curves that measured as what progresseed the most after skeletal maturity?
50-75 degrees of thoracic curves
Lumbar curves at what degree tend to progress? What is often accompanied by?
50 degrees
Transitory shift between the lower vertebrae
What are the common side effects of untreated curves?
Shortness of breath in the presence of a thoracic curve of 80 degrees or more
Chronic back pain
Cosmetic concerns
Studies have shown the the corrective for ces of a brace are what compared to what?
Corrective forces of the brace are passive in nature and that the predominant corrective component is the transversee loading of the spine through the use of corrective pads.
What type of scolotic bracing is better than the rest?
TLSO or Milwaukee orthosis are better and full time versus part time bracing is better.
What is the treatment for patients with EIS with an RVAD of less than 20 degrees.
Have infant sleep in prone position rather than supine with follow-ups every 4-6 months
What should the treatment be for patients with EIS and a RVAD greater than 20 degrees?
Nonoperative treatment until a one-time spinal stabilization procedure can be performed.
When can scoliosis be reversed?
Children with progressive infantile scoliosis who were treated with serial corrective plaster casts. They were then fit into TLSOs to maintain the correction that was achieved through casting
What is the most common curve in juvenile scoliosis?
Convex-right thoracic curve patterns
Juvenile-onset scoliosis are more likely to have what and are less likely to what?
Have curves that progress and are less likely to respond to bracing. They will most likely require surgical treatment
In patient with juvenile-onset scoliosis, if the apex of the curve is at T8, T9, or T10, what percent have a chance of requiring spinal arthrodesis by the age of 15?
80%
For adolescent idiopathic scoliosis, what degree of curve requires treatment?
30 or 45 degrees should have an orthosis prescribed
For a patient with a Risser sign of 0 in adolescent idiopathic scoliosis, what degree of the curve should require treatment?
25 degrees
In general, adolescents with curves greater than 45-50 degrees cannot what?
Be treated with an orthosis
Skeletal mature individuals with curves exceeding what, are at risk for what?
50 to 55 degrees
Continued curve progression
To be considered effective, orthotic treatment must prevent what?
Curve progression in those who are most at risk (curves of 25 to 45 degrees in Risser 0 or 1), result in an acceptable cosmetic appearance at the end of treatment, and reduce the need for surgery.
What is the primary advantage of the Milwaukee brace?
The ability to apply corrective forces at the convexity of a deformity in a way that unencumbered by a concave side force that could prevent the torso and spine from sufficiently shifting in a corrective manner.
The directionof the forces being applied, the location, magnitude, can all be adjusted easily.
A milwaukee brace is capable of providing greater stability to a primary curve where, compared to a low-proile thermoplastic TLSO which can offer greater stability to a primary curve where?
Milwaukee: Primary thoracic curve
Low-profile: Primary lumbar curve
The Milwaukee brace has been shown to be effectibe in controlling what?
Curve progression in idiopathic scoliosis
The boston brace is effective in treating what?
Single or double curve patterns in which the apex of the most cephalad curve is located at T7 or below.
What was the recommended time of wearing the scolotic braces?
20-22 hours
Then it went to 16 hourse due to compliance issues
What was the concept for the Charlseton brace?
Worn at night for only 8-10 hours, this orthosis is designed to take advantage of the recumbent position to shift the convexity of the ccurve as much as possible towards the midline, and unbending the curve above the apex in the opposite direction for maximum side-bending correction.
The charleston brace should be reserved for patient only with which type of curves?
Single lumbar
Thoracolumbar curves with magnitude of 35 degrees or less
What is another brace used only at night?
Providence brace
How is the providence brace similar and different to the charleston brace?
It is similar in that it is designed to shift the convexity of the curve to midline.
It is different in that it is not designed to unbend the curve in the opposite direction superior to the apex.
What is scheuermann’s kyphosis?
A spinal pathology consisting of vertebral endplate irregularities and wedging with more than 5 degrees of anterior wedging of three consecutive adjacent vertebral bodies at the apex of the kyphosis,
Irregular vertebral apophyseal lines combined with flattening and wedging.
Narrowing of the intervertebral disk space
Variable presence of Schmorl nodes
What are schmorl nodes?
The penetration of disk material and subsequent alteration of the endochondral ossificationprocess of the anterior vertebral body.
How is scheuermann’s kyphosis characterized?
A rigid deformity that cannot be reasonably corrected by passive manipulation or by the patient’s active extension.
There is also a distinct dorsal kyphosis as seen laterally with the Adams forward bending test
What is the normal range of thoracic kyphosis?
20-45 degrees using the Cobb method of measurement.
What is the difference between adolescent postural roundback and scheuermann’s kyphosis?
Postural deformiy can more easily be reduced by active contraction of the erector spinae muscles and they lack the vertebral wedging in Scheuermann’s disease.
Where can scheuermann’s kyphosis occur in the spine?
Thoracic
Thoracolumbar
Lumbar
How is Thoracic Scheuermann’s kyphosis defined?
Having an apex between T7 and T9
How is thoracolumbar Scheuermann’s kyphosis defined?
T10 and T12
Lumbar Scheuermann’s kyphosis is usually associated with what?
Male patients presenting with back pain and usually athletic patients or those performing hard labor
What are the common complaints of scheuermann’s kyphosis?
Back pain
Fatigue
What are the neurologic complications that are rare but can occur in scheuermann’s disease?
Extradural spinal cyst
Compression of the cord at the apex of the kyphos
Disk hernia at the apex of the kyphos
What is the treatment for adolescents with scheuermann’s kyphosis?
None. Both surgical and nonsurgical treatments are contraindicated
For patients with few symptoms and a deformity, what treatments for scheuermann’s kyphosis is suggested?
Exercise programs to strengthen spinal extensors (for thoracic or thoracolumbar kyphosis), or abdominal muscles (for lumbar hyperlordosis).
What is the goal of an orthosis for treating scheuermanns kyphosis?
Diminish any pain present, control the deformity, and to reconstitue the anterior vertebral height through the application of spinal extension forces.
Which brace is effectibe in treatment of thoracic scheuermann’s kyphosis curves ranging from 50 to 75 degrees?
The milwaukee brace
It places a passive at eh midthoracic level of the spine and an extension inducement as the patient reacts actively in response to the neck ring.
For a thoracolumbar deformity resulting from scheuermann’s kyphosis what brace can be used?
A thermoplastic TLSO with apporpriate anterior sternal extension
What is the wear time of an orthosis for treatment of scheuermann’s kyphosis?
Full time, only take off 1-2 hours a day.
In Scheuermann’s kyphosis, where isthe pressure directed in a Milwaukee brace?
The inferior point of pressure comes from the thermoplastic pelvic portion of the orthosis (known as the girdle). The acurrate fit of the girdle is very important.
The pads exert anteriorly directed pressure at and just inferior to the apical vertebrae of the curve.
The cephalad and third point of force depends on the active response by the patient. The neck ring invokes a posteriorly directed stimulus superior to the apex of the thoracic kyphosis, and it relies on the patient to actively pull away.
What are the three criteria that the pelvic girdle of the Milwaukee brace should fulfill in treating scheuermann’s kyphosis?
Decrease lumbar lordosis
Shaped to lock onto the pelvis without impinging on the iliac crests
It should have a snug-fitting and appropriately contoured waist groove to prevent superior or inferior migration of the orthosis.
The success of the Milwaukee brace is dependent on what?
Active correction by the patient.
The Thermoplastic TLSO relies on what when treating scheuermann’s kyphosis?
Passive correction of the kyphotic deformity
How is the mold for a TLSO usually taken when treating scheuermann’s kyphosis?
In a supine position with the knee bent to reduce lumbar lordosis.
What are the different adjustments an orthotist can make to increase the amount of corrective for when treating scheuermann’s kyphosis with a Milwaukee brace?
Thicken the pads mounted to the paraspinal bars
Countour the paraspinal bars into an antikyphotic posture
Raise the anterior superstructure, increasing the amount of effort required to decrease the kyphotic cure
The neck ring can be translated more posteriorly this necessitates a dynamic postural correction.
The amount of lumbar lordosis can be decreased by contouring the relationship between the inferior portion of the paraspinal uprights and the anterior superstructure.
How can a TLSO be adjusted to apply greater correction when treating scheuermann’s kyphosis?
Increasing the thickness of the pads utilized in the passive correction of the deformity.
When should patients with Scheuermann’s kyphosis be treated?
Before they reach skeletal maturity and with a curve of 60 degrees or greater.
