Scoliosis/Raynauds Flashcards
Scoliosis
general
Structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane, usually accompanied by rotation of variable amounts
♀>♂ (rapid growth between 10-15 years → increased curvature change)
scoliosis
Classification according to severity:
(Degrees)
Classification according to severity:
Mild: 10–15 degrees
Moderate: 20–45 degrees
Severe: > 50 degrees
Scoliosis
classfiication by cause
Genes
Classification by cause:
Idiopathic
Most common type (70-90%)
Possibly a defect in the composition of intervertebral discs (↓ amounts of glycosaminoglycans to act as a shock absorber)
Commonly presents in children 10-18 years
Congenital
Mutations in the CHD7 and MATN1 genes
Acquired
Neuromuscular (CP or muscular dystrophy)
scoliosis
Clinical Presentation
Only 1 in 200 patients become symptomatic
Pain
Sharp and/or burning back pain
Associated with movement
Neck pain
Headaches
Chest pain
Lung dysfunction
Dextroscoliosis: spinal curvature to the right
Levoscoliosis: spinal curvature to the left
Scoliosis
Suspect scoliosis when..
Suscept scoliosis when…
A shoulder appears higher on one side versus the other (usually the right shoulder higher)
Clothing does not hang straight
Leg-length discrepancy
Asymmetry of the chest wall
Often detected during routine school or medical provider screening
Scoliosis
Assessment
Scoliometer
Measures theangulationof thespine(angle of trunkrotation) while the individual bends forward
Consistent, standardized way to measure
Technique:
Patient bends forward, as if they are diving
Deviation of the ball (in the meter) from the center is noted in scoliosis
Measurements of > 5 degrees is abnormal → spine x-ray
Scoliosis
Spine Xray
Recommended views:
Standing posteroanterior (PA) view and measuring the Cobb angle
> 10°defined as scoliosis
Greater the curve, the greater the likelihood that it will progress after the skeleton matures
Prognosis depends on site and severity of the curve and age at symptom onset
Standing lateral view
Scoliosos
MRI spine indications
Patients under age 10
Rapid progression (Cobb angle ≥ 10° per year)
In patients with:
Increased pain
Associated neurologic symptoms
Abnormal findings on the plain radiographs
Left thoracic curvature
Scoliosis
When to refer to ortho
Scoliosis
Tx
Serial radiographs every 4-6 months to monitor for progression
Moderate curves (20 to 40°) are treated conservatively to prevent further deformity
Physical therapy
Bracing
Severe curves (>40°)
Surgery (spinal fusion with rod placement)
Highly invasive and there is a risk for chronic pain and infection
Raynaud’s Phenomenon
general
Abnormally marked and sudden vasoconstrictive response to cold temperature, emotional stress, or vibration
Associated with sharply demarcated triphasic color changes
Usually, but not always limited to the fingers and toes
Types:
Primary
Secondary
Prevalence:
3-5% of the population
♀>♂
Raynaud’s Phenomenon
Primary Raynauds
Primary Raynaud’s - (Raynaud’s disease)
Most common type (> 80% of cases)
Idiopathic
25% of patients have a positive family history of the condition
Onset:
Begins at a younger age (15-25 years)
Unusual over age 40 years
raynauds
Secondary Raynauds
Secondary Raynaud’s – (Raynaud’s syndrome)
Accompanies various disorders and conditions, mostly connective tissue disorders
Associated with drug use
Onset:
> 30 years
Raynauds
Patho (phases)
High levels of vasoconstrictors and low levels of vasodilators
Ischemic phase
Arterial vasospasm causing distal blanching and transient numbness
Hypoxic phase (cyanosis)
Dilation of capillaries and venules containing deoxygenated blood causing cyanosis
Hyperemic phase (rubor)
Rewarming and resolution of vasospasm, leads to oxygenated blood being delivered to the dilated capillaries and venules, causing hyperemia and erythema
Primary Raynaud syndrome
Clin man
Mild and reversible condition
Symmetric
Middle 3 fingers are commonly affected; rarely affects the thumb
Usually lasts less than 20 minutes
No trophic changes (skin or subcutaneous changes, ulcers, or gangrene)
Often goes into remission
Secondary Raynaud syndrome
Clin man
More severe form (underlying damage to arteries)
Asymmetric or unilateral
Trophic changes (pitting scars, ulcers, and rarely gangrene)
Raynaud’s secondary to systemic sclerosis tends to cause extremely painful, infected ulcers
Sclerodactyly
Puffy digits with skin tightening
Remission is uncommon
Systemic sclerosis patients with ulcerations from Raynaud’s
Raynauds
Dx
Made clinically
Testing to diagnose an underlying cause
Labs (collagen vascular diseases)
ESR and/or CRP
Antinuclear and anti-DNA antibodies
Rheumatoid factor
Anticentromere antibody
Anti-cyclic citrullinated peptide [CCP] antibodies
Anti-scleroderma [SCL] 70 antibody
Vascular testing
Measuring digital pulse wave forms and pressures
Features warranting further investigation for SRP include:
(note from ppt)-secondary Raynard’s
Older age at onset
Male patient
More severe symptoms or fixed, irreversible lesions
Asymmetric involvement
Systemic signs of disease
Raynauds
Nailfold capillary microscopy
Normal / Abnormal
Nailfold capillary microscopy
Assessment of structural alterations of the microcirculation
Normal
Vessels are thin, uniform, evenly spaced, and symmetric in distribution
Capillary loops have a hairpin appearance
Abnormal
Absent (“dropout” areas) or dilated capillary loops
Vessel are irregular, tortuous, elongated, bizarre, bushy, engorged, or corkscrew in appearance
Spacing between loops may be uneven or irregular
Primary Raynaud syndrome
Management of Mild cases
Cessation of smoking
Keeping warm by avoiding cold exposure and wearing proper clothes
Avoiding or managing emotional stress
Avoiding vasoconstrictive drugs (nasal decongestants, amphetamines, methylphenidate sumatriptan)
Primary raynauds syndrome
management of Severe cases
Managed by a rheumatologist
Calcium channel blockers (CCBs) – vasodilates blood vessels- nifedipine or amlodipine
Alpha-blocker – relaxes blood vessels- prazosin
Anticoagulant therapy for severe ischemia with the potential for digital loss
Secondary Raynaud syndrome
management
Managed by a rheumatologist
Focuses on the underlying disorder
Calcium channel blockers (CCBs) – vasodilates blood vessels - nifedipine or amlodipine
Ischemic ulcers
Anticoagulant therapy
Antibiotics, analgesics, and occasionally surgical debridement
Raynauds
Key Points
Raynaud syndrome is reversible vasospasm of parts of the hand in response to cold, emotional stress, or vibration
Raynaud syndrome may be primary or secondary to another disorder, typically one affecting connective tissue
Primary Raynaud syndrome, unlike the secondary form, rarely causes gangrene or tissue loss
Diagnosed clinically, but consider testing to diagnose a suspected cause
Avoid cold, smoking, and any other triggers
Give a vasodilating calcium channel blocker or prazosin
