Paediatric Idiopathic Scoliosis Flashcards

Question 1

Q

Define adolesent idiopathic scoliosis?

Answer

A

scoliosis in children >10 years old
most common type of scoliosis

Question 2

Q

What is the epidemiology of adolscent idopathic scoliosis?

Answer

A

Incidence of 3% for curves 10-20^o
Incidence of 0.3% for curves >30%
10:1 Female vs male for curves >30^o
- 1:1 M:F for small curves
- right thoracic curves most common
- left curves rare- need MRI to rule out cyst/syrinx

Question 3

Q

Describe the pathophysiology of adolescent idopathic scoliosis?

Answer

A

Unknown
potential causes
- Multifactorial
- hormonal- melatonin
- Brain stem
- proprioception disorder
- platelet
- calmodulin
most have positive FHX

Question 4

Q

What is the prognosis of adolscent idopathic scoliosis?

Answer

A

Natural hx
- increased incidence of acute and chronic pain in adults if left untreated
- Curves >90^o assoc with cardiopulmonary dysfunction, early death, pain and decreased self image

Question 5

Q

What are the risk factors for curve progression?

Answer

A

Curve Magnitude
- before skeletal maturity
  - >25⁰will continue to progress
- after skeletal maturity
  - >50^o thoracic will progress 1-2^o pa
  - >40^o lumbar will porgress 1-2^o pa
Curve Type
- Thoracic more likely to progress than lumbar
- double curves more likely to progress than single curves
Remaining skeletal growth
- Younger age <12yrs
- Tanner stage <3 females
- Risser stage <3 females
- open triradiate cartilage
peak growth velocity
- best predictor of curve progression
- in females just before menarche & before Reisser 1 ( girls reach Sk maturity 1.5yrs post menarchy)
- if curve is 30^o B4 peak growth velocity strong likelihood of surgery

Question 6

Q

What is Risser Stage used for and can you describe it?

Answer

A

Used to identify Maturity of skeleton
V is fused
1 is apophysis at anterior edge

Question 7

Q

How is adolscent idopathic scoliosis identifed?

Answer

A

School screening on adams forward bending test
7^oabnormal = 20^ocoronal plane curve
axial plane deformity indicates stuctural curve- see pic
forward bending sitting test can eliminiate leg length inequality as cause of scoliosis

Question 8

Q

What other important signs are seen on examination in a pt with adolscent idopathic scoliosis?

Answer

A

Leg length inequality
midline skin defects- hairy patches, dimles, nevi
- signs of spinal dysraphism
shoulder height difference
truncal shift
rib rotational deformity- rib prominence
waist asymmetry and pelvic tilt
cafe-au-lait spots
foot deformities
- cavovarus-? neural axis deformity =MRI
Asymmetric abdominal reflexes
- preform MRI

Question 9

Q

What is seen on xrays with a pt of adolscent idopathic scoliosis?

Answer

A

Standing PA and lateral
- Cobb angle
  - >10⁰ = scoliosis
- Spinal Balance
  - plump line C7-post -superior corner S1

Question 10

Q

When are MRI indicated in adolscent idopathic scoliosis?

Answer

A

left sided curves
rapid progression
excessive kyphosis
neurological symptoms
assymetrical abdominal reflexes
foot deformities

idea to rule out intraspinal anomalies

Question 11

Q

What is the tx of adolscent idopathic scoliosis?

Answer

A

Non operative

Obervation alone
- if cobb angle <25^o
- serial xrays review progression
Bracing
- Cobb angle 25-45^o
- in immature Pt Reisser 0-2
- goal to stop progression not correct deformity__
  - poor prognosis
  - male, obesity, hypokyphosis, noncompliant

Surgery

Posterior spinal fusion
- Cobb >45^o
- gold standard for thoracic/ double curves
Anterior spinal fusion
- best for thoracolumbar/ lumbar cases with normal sagittal profile
Anterior/Posterior spinal fusion
- large curve >75o & stiff
- young age risser 0
- prevent crankshaft phenomenon

Question 12

Q

Describe the technique of bracing in adolscent idopathic scoliosis?

Answer

A

recommended for 16-23 hours a day until skeletal mature or surgical innervention necessary
Brace types
- Curves above T7
  - milwaukee brace- Cervicothoracolumbosacral orthosis-CTLSO
- Apex at T7 or below
  - Thoracolumbosacral orthosis TLSO
  - boston brace

Question 13

Q

What is the techique of surgery

Answer

A

Posterior spinal fusion
- aims
  - to include enough levels to maintain sagittal and coronal balance whilst being minimal as safely possible
  - typical fusion prox end of vertebra to one/two levels cephalad to stable vertebra
- Harrington technique
  - 1 level above to 2 levels below the end vertebra
- L5 level- cochran found increaed incidence of low back pain with fusion to L5, and lesser extent L4
  - try to avoid fusion L4/5
  - pelvis almost never fused in idiopathic scoliosis

Question 14

Q

What is monitored in adolescent idiopathic scoliosis surgery?

Answer

A

Somatosensory -evoked potentials SSEPs
- allow identication of injuries from positioninf
- most common reversible intraop neurological injury
Motor-evoked potential - MEPs
- provide intraop warning of impeding spinal cord dysfunction

Question 15

Q

What happens if neurological injury occurs in theatre whilst monitoring SSEPs/ MEPs?

Answer

A

Lessen reverse correction
check HB and transfuse
elevate BP
administer Stagnaras wake up test
- waking the patient during the surgery and asking them to move their feet.
remove instrumentation if spine stable

Question 16

Q

Complications of spinal surgery on adolescent idiopathic scoliosis?

Answer

A

Neurological injury
- 1:1000
Pseudoarthrosis
Infection 1%
- late pain
- incision often looks clean
- Propionibacterium acnes - most common organism for delayed infection
Flat back syndrome
- early fatigability & pain due to loss of lumbar lordosis
Crankshaft phenomenon
- rotational deformity of spine ctreated by continued anterior spinal growth in setting of post fusion
- avoid by preforming anterior discectomy + fusion with post fusion in young pt
SMA syndrome- superior mesenteric artery syndrome
- pc bowel obstruction
- tx with NG tube and iv fluids
Hardware failure
- late rod breakage

Question 17

Q

What is juvenile idiopathic scoliosis?

Answer

A

scoliosis in children <10 years

Question 18

Q

What is the epidemiology of juvenile idiopathic scoliosis?

Answer

A

Greater in females than males
mainly appear right sided thoracic curves

Question 19

Q

What are the associated conditions of juvenile idiopathic scoliosis?

Answer

A

high incidence of neural axis abnormalities = 18-25%
- Syringomyelia
  - cyst/tubular cavity within spinal cord
- Arnold-Chiari syndrome
  - cerebellar tonsil are elongated. Protrude thru thr opening of base of the skull and blocking CSF flow
- Tethered cord
- Dysraphism
- spinal cord tumours

Question 20

Q

How do they present with juvenile idiopathic scoliosis?

Answer

A

School screening
ADAMS forward bending test
- abnormal 7^o= 20^o coronal plane curve
cafe au lait spots
leg length discrepancy
shoulder height difference
truncal shift
rib rotational
waist asymmetry
foot deformity- cavovarus
asymmetrical abdo reflexes

Question 21

Q

What is seen on imaging of juvenile idiopathic scoliosis?

Answer

A

Xrays PA & lateral upright
Cobb angle >10⁰
MRI those who <10 years with curve >20^o

Question 22

Q

What is the tx of juvenile idiopathic scoliosis?

Answer

A

Non operative

Observational
- curves <20^o
- freq radiographs- see curve progression
Bracing
- curves 20-50^o
- prevent curve progression, no correct deformity
- CI thoracic hypokyphosis
- 16-23 hrs until skeletal mature

Surgery

Non fusion proceedure- growing rods
- Curves >50^o in small children- alot growth left
- allow continued spinal growth
- Definitive PSF +ASF when child grown
Anterior/posterior fusion
- Curves >50^o in younger pts
- to prevent crankshaft phenomenon
Posterior Spinal fusion
- curve >50^o in older pt skeletal mature
- gold standard doublecurves/ thoracic curves
Anterior spinal fusion
- curve >50 degrees with thoracolumbar/thoracic cases w normal sagittal profile

Question 23

Q

Define infantile idiopathic scoliosis?

Answer

A

Scoilosis that presents prior to age 3

Question 24

Q

What is the epidemiology of infantile idiopathic scoliosis?

Answer

A

4% of idiopathic scoliosis cases
more common in MALES
autosomal dominance w variable penetrance
location
- usually LEFT THORACIC
Risk factors
- most resolve spontaneously
- apical vertebra rib overlap places curve at high risk of progression

Question 25

Q

What is infantile idiopathic scoliosis associated with ?

Answer

A

Plagiocephaly- skull flattening
Congenital defects
Neural axis abnormalities
- 22% pt with curves >20^o
- 80% of these will need neurosurgery
Cardiopulmonary involvement
- pulmonary function affected curves >60^o
- Symptomatic when curve >90^o

Question 26

Q

What do you look for on exam of a pt with infantile idiopathic scoliosis?

Answer

A

Skin
- cafe- au- lait- NF1/2
- patches of hair, dimpling, naevi- spinal dysraphism
Cranial
- plagiocephaly
Motor
- milestones
- lower extremity - cavovarus
- abdo reflexes- syrinx

Question 27

Q

What investigations are useful in infantile idiopathic scoliosis?

Answer

A

Cobb angle
evaluate phase of rib position- medial rib position w repsepct to apical vertebra
- phase 1
  - no rib overlap
- Phase 2
  - rib overlap with apical vertebra
  - high risk of curve progression
- Rib Vertebrae angle difference - RVAD/Mehta angle
- >20 linked to high rate of pregression
- <20 assoc with sponataneous recovery

Question 28

Q

What is the tx of infantile idiopathic scoliosis?

Answer

A

Non operative

Observe alone
- Cobb angle <30^o
- RVAD <20^{o ( rib vertebrae angle difference)}
- 90% resolve spontaneously
Serial Mehta casting (derotatonal )or thoracolumbosacral orthosis TLSO
- Cobb angle 25-30
- Phase 2 rib vertebra relationship

Operative

Growing rod construct ( dual rod or VEPTR)
cobb angle >50-60 degrees
- allow growth of spine up to 5cm
- anchors proximal and distally
- serial lengthening

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Paediatric Idiopathic Scoliosis Flashcards

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