Scoliosis Flashcards
Scoliosis definition
- axial deviation of the spine in the frontal plane
- defines a spatial deformity due to the additional rotation of the vertebrae with the presence of a hump and hypokyphosis (in the sagittal plane)
Adolescent Idiopathic Scoliosis (AIS)
- Onset after the age of 10 years
- Most frequent entity (1- 4% incidence/ 0,1% with a curve more than 40 degrees)
- More frequent in females(10 vs. 1)
May present an evolutive potential (progression + 10 degrees /year for curves ranged 10-20 degrees and +5 for 20-30 degrees). Curves above 60 degrees are evolving constantly during life span
AIS
clinics
- Posture
- Thoracic hypokyphosis
- Shoulder/pelvic imbalance (anterior prominence of the shoulder on the convex side)
- Abdominal and lower limb reflexes should be checked
- Adams test– thoracic hump on the convexe side
- LLD
AIS - imagistics
- X-rays (head- spine-pelvis – frontal, profile and lateral bending)
- IRM – possible associated medullary malformations
- CT-CT-3D – vertebral dimensions and shape/spatial view of the whole spine
- X-rays and CT – useful in preoperative planning and follow-up
Diagnosis is made with
- full-length standing PA
- lateral spine radiographs.
AIS - natural evolution
Curve progression
Risk factor Curve grade Before skeletal maturity : > 25° evolutive potential After skeletal maturity : Thoracic curves > 50° progress 1-2° / year Lumbar curves > 40° progress 1-2° / year
Risser sign
- Measures the progression risk related to skeletal age
- 4-5 at the end of skeletal growth
Risser Stage (0-1)
- Risser 0 covers 2/3 of the pubertys’ growth sprout
- It correlates to the accelerated height growth
peak growth velocity
- is the best predictor of curve progression
- in females it occurs just before menarche and before Risser 1 (girls usually reach skeletal maturity 1.5 yrs after menarche)
- most closely correlates with the Tanner-Whitehouse III RUS method of skeletal maturity determination
- if curve is >30° before peak height velocity there is a strong likelihood of the need for surgery
AIS – natural evolution
- Risser 0-1
- Risser 0 covers 2/3 of the pubertys’ growth sprout
- It correlates to the accelerated height growth - Open triradiate physis
- Curves >30° before the apex of the growth sprout – great evolutive potential – great probability of surgery
AIS - treatment : 1+2
- Observation – curves below 25 degrees – serial X-rays
- Orthotics (Bracing)
- Indications
Cobb - 25° - 45°
Flexible deformity with Risser 0-2
Aim – to stop curve progression NOT to correct
AIS - treatment : 3
Surgery Posterior spinal fusion indications - Cobb > 45° - All types of AIS - Golden standard for thoracic and thoracic-lumbar curves
Anterior spinal fusion
indication
- Effective in lumbar and thoracic-lumbar curves with thoracic kyphosis and normal lumbar lordsis
Double anterior and posterior approach indication - Curves above 75° or very stifff - Decreased bony age (Risser 0, girls <10 years, boys < 13 years) - To avoid crankshaft
AIS – surgical complications
- Neurologic lesions
- Paraplegia - 1:1000
- Higher risk in scolio with hyperkyphosis - Pseudarthrosis (1-2%)
- Late pain, hardware breakdown - Infection (1-2%)
- Late pain, late fistula
4.Crankshaft
Rotational deformity due to anterior restant growth potential
5.Flat back
Straight spine in the sagittal plane – NO lumbar lordosis – low back pain – requires re-intervention to correct the sagital plane
6.Hardware breakdown
Infantile Idiopathic Scoliosis (IIS)
- Onset before the age of 3 years
- Most curves are right sided
- Boys > Girls
4.Healthy child
May associate: DDH, mental impairment, heart malformations
5.Dg. clinical, X-rays, CT, CT-3D, MRI
IIS evolution
- Some of the curves regress spontaneously
- Progression established by Rib-Vertebra- angle difference (RVAD)
Phase 1
RVAD > 20 degrees – 80 % progression
RVAD < 20 degrees - < 15% progression
Phase 2
100 % progression
Juvenile Idiopathic Scoliosis (JIS)
- Diagnosis – age between 4-10y
(SRS Terminology Committee) - 10-15 % of idiopathic scolio
- Boys > Girls
- MRI – 20% of the patients with a curve > 20° –medullar malformation
Arnold-Chiari
siringomyelia
JIS evolution
- Curves > 30 ° - always evolves
- Conservative treatment – but most require surgery
- Untreated – high mortality rates
Arnold-Chiari Syndrome
cerebellar tonsil are elongated and protruding through the opening of the base of the skull and blocking CSF flow)
A Chiari malformation (Arnold Chiari Syndrome) refers to the descending of a section of the brain through an opening at the bottom of the skull. This cavity would usually be clear, and the blockage caused by the abnormally positioned tissue can cause a number of problems, including stopping the healthy flow of fluid - known as cerebrospinal fluid - along the spinal canal. The part of the brain affected is known as the cerebellar tonsils, in cases of Chiari malformation they protrude too low, reaching past the base of skull.
siringomyelia -
- cyst or tubular cavity within spinal cord
- can be seen in a scoliotic curve without rotation
- can manifest as an asymmetric umbilicus reflex
the watery liquid known as cerebrospinal fluid (CSF)—which normally surrounds and protects the brain and spinal cord—builds up within the tissue of the spinal cord, expands the central canal and forms a syrinx. Generally, a syrinx develops when the normal flow of CSF around the spinal cord or lower brain stem is disturbed. When syrinxes affect the brain stem, the condition is called syringobulbia.
JIS evolution
- Curves > 30 ° - always evolves
- Conservative treatment – but most require surgery
- Untreated – high mortality rates
Congenital scoliosis (CS)
- Spinal defects in the 6th intrauterine life (embryonic formation)
- Unknown causes …
- Alcohol, Insulin, CO, antiepileptics, boric acid, hyperthermia, etc
- Frequent associates other malformations - 60% (heart, kidney, nervous system)
- Sporadically, familial (1-4%) or in some syndromes
CS classification
CS due to
Formation defects
Segmentation defects
Mixed
CS diagnosis
- 3D-Ultrasonography (Ritsuko K Pooh, Asim Kurjak)
2. Mandatory – CT & MRI– X-rays invisible malformations – 30%
CS clinics
75% visible at birth
- Localized hyperpigmentation
- Abnormal hairy patches
- Dermal sinuses
CS imagistics
- CT-CT-3D
2. MRI
CS prognosis
75% progress – accelerated – first year of life & puberty growth sprout
Progressive potential related to malformation
- Segmented HV & longitudinal bony bar - 10°/an
- Longitudinal bar
- 2 succesive HV
CS prognosis
- Fully segmentated HV
- Hemisegmentată HV
- Trapezoidal vertebra
- Unsegmented HV
CS progression
even for small curves (<40o) – surgical indication
Neuromuscular Scolio
- Cerebral palsy
- Spinal amiotrophy
- Muscular dystrophy
- Poliomyelitis
- Arthrogriposis
Sindromic Scolio
- Marfan
- Ehlers- Danlos
- Dwarfism
- Neurofibromatosis(von Recklinghausen)
- VATER/VACTERL
Thoracic Insufficiency Syndrome (TIS)
The incapacity of the thoracic cage to ensure proper lung development and normal breathing (R. Campbell)
Diagnosis - clinical + imagistics (X, CT-3D, CT) + functional respiratory exams
CS – main cause
TIS
Mechanism
Thoracic compliance – low / undersized lung → Reduced Vital Capacitaty (below 80% of normal) → Hypotrophia → weak respiratory muscles → respiratory insuficiency and pulmonary hypertension → Death by cardio-respiratory insufficiency
Therapeutic treatment options of TIS
Classical treatment
Non-surgical
- Observation
- Plaster casting
- Bracing 25°- 45°
Surgical
- Anterior/posterior hemiepiphysiodesis
- Anterior & posterior fusion
- Spine osteotomy
Disadvantages of Therapeutic treatment options of TIS
- Crankshaft
- Complexe surgical procedures
- Affects spine growth
- Affects thoracic and lung development
Standard modern treatment
SKAGGS
Surgery
- Fusion
- Growth friendly techniques
- Distraction-based ( <8 years)
- Growing Rods
- VEPTR
- Growth guidance (<8 years)
- Shilla™
- Luque
- Distraction-based ( <8 years)
Safety Algorrhytm
Conservative treatment– until losing curve control
+ spinal issues – Shilla™
+ thoracic issues – VEPTR
Maturity– hardware conversion and final spinal fusion
Safety algorythm part 2
- Early Diagnosis – proper diagnosis - proper treatment
- Always remember SPINE-THORAX-LUNG interrelation
- “Growing devices” correct and stabilizes the spinal deformity and ensures thoracic and lung development
