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OMM M1T2 test 1 > Structural Scoliosis > Flashcards

Structural Scoliosis Flashcards

0
Q

Sidebending and rotation are what type of motions?

A

Coupled

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1
Q

Define scoliosis.

A

Any lateral deviation of the spine in the coronal plane greater than 10 degrees from the normally straight vertical line of the spine.

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2
Q

The vast majority (99.9999%) follow what type of mechanics?

A

Fryette Type I

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3
Q

What creates the rib hump of scoliosis?

A

The rotational component

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4
Q

Most scoliosis is accompanied by what?

A

Some degree of kyphosis

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5
Q

Scoliosis is named for the side of what?

A

Convexity

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6
Q

When is scoliosis generally discovered?

A

During routine health screening exams. In a study of more than 2000 children, 4.1% had visible asymmetry, 1.8% had a scoliosis greater than 10 degrees, and 0.4% required actual treatment.

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7
Q

When taking a history, you want to know what about the scoliotic curve?

A
  1. origin of curve (sudden onset or following trauma)
  2. presence of pain (pain suggests trauma, disease, etc.)
  3. injury
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8
Q

What should you look for in your physical examination when diagnosing scoliosis?

A

Static structural - mid-gravity line, symmetry
Forward bending - follows 3rd law of spinal motion; flexing the spine should exaggerate kyphosis, sidebending, and rotation - this makes the rib hump more visible (can also make rotation in lumbar spine more visible)

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9
Q

What is the Adam test?

A

Patient stands with feet together, then forward bends. If scoliosis presents, you will see a rib hump.

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10
Q

How can you measure the rib hump?

A

Using a protractor or inclinometer, measure across the apex of the rib hump and compare with the horizontal. If the rib hump measurement is greater than or equal to 7 degrees, further evaluation is warranted.

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11
Q

What must you always perform when diagnosing scoliosis?

A

A complete neurologic examination. The presence of neurologic deficits requires a careful search for the reasons behind these findings. Idiopathic scoliosis should NOT cause neurologic deficits. Get an MRI of the entire spinal canal from foramen magnum to sacrum.

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12
Q

What neurologic conditions can mimic idiopathic scoliosis?

A

Syringomyelia and neurofibromatosis

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13
Q

What parts of the body, besides the spine, should you examine when diagnosing scoliosis and why?

A

Examine extremities for arachnodactyly & joint laxity to rule out Marfan syndrome or Ehlers-Danlos syndrome.
Search for skin abnormalities overlying the spine which may indicate the presence of spinal anomalies causing a tethered spinal cord.

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14
Q

What are the curve patterns?

A

C-shaped, S-shaped, and Complex

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15
Q

Define a major curve.

A

Curve with the largest degree of measurement.

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16
Q

Define a minor curve.

A

Curve with the lesser degree of measurement; may be compensatory.

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17
Q

Define a double major curve.

A

An S-shaped curve with both upper and lower curves measuring about the same.

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18
Q

How do you measure the Cobb angle?

A

Draw lines through superior and inferior end plates; measure angle created where the lines meet.

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19
Q

What are the determining factors of scoliosis management?

A 
Age of patient
Skeletal maturity
Type of curve
Severity of curve
Duration of curve
Complicating factors
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20
Q

What are the age groupings for scoliosis management, and what are the diagnoses?

A

Infantile: 0-3 years
Juvenile: 3-10 years; onset prior to 10 is associated with an occult intraspinal anomaly in 20% of cases - treat with OMT if no other abnormalities discovered.
Adolescent: 10-end of bone growth; majority are idiopathic
Adult: after end of bone growth; usually associated with disease

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21
Q

The origin of scoliosis can be?

A

Idiopathic, congenital, or paralytic

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22
Q

You can measure the severity of the curve via what methods?

A

Cobb angle, level of apex, or degree of rotation

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23
Q

A bigger curve at the apex of this region is the worst.

A

Thoracolumbar; has a tendency to collapse more.

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24
Q

What are complicating factors of scoliosis?

A 
Pulmonary compromise
Cardiac compromise
Neurologic compromise
Progression of curve
Degenerative spondylosis
Pelvic distortion
Collapse of curve
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25
Q

Curves greater than ___ degrees are at an increased risk for shortness of breath.

A

50; odds ratio 15 at 30 year follow-up and 4 at 50 year follow-up

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26
Q

Curves greater than ___ degrees Cobb method measurably impair respiratory function and impair venous return to the heart.

A

70

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27
Q

What percentage of women diagnosed with Mycobacterium avium complex (a rare infection) had a scoliosis of greater than 10 degrees?

A

52%

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28
Q

What do you see with rib cage distortion?

A

Ribs on concave side are jammed together and ribs on convex side are farther apart. This impacts the thoracic viscera.

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29
Q

What happens with pelvic distortion?

A

The pelvis rotates on lower extremities - bone remodels and distorts after a period of time.

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30
Q

What is Wolff’s law?

A

Bone is laid down along lines of stress.

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31
Q

What is neurologic compromise?

A

Presentation of new neurologic deficits can signal the beginning of spinal cord or cauda equina compression.

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32
Q

When would you see progression of curve?

A

Adult progression of scoliosis is rare unless the curve exceeds 50 degrees. At this measurement, the scoliosis can then worsen at a rate of 1-2 degrees per year. Should not see this in today’s world due to early intervention. Would see this if parents did not allow earlier proposed intervention (e.g. surgery) or patient lacked access to proper medical care.

33
Q

How do you determine the amount of vertebral rotation?

A

Look for pedical shadow; rotation loses the shadow

34
Q

What can you see with degenerative spondylosis as a complicating factor?

A

Stage of spondylotic instability can cause progression of the curve, and even sudden curve decompensation & collapse
Rib cage literally ends up sitting on side of pelvis
Contact with liver can result in abnormal liver function tests
Curve collapse can also result from trauma

35
Q

How do you perform a plumb line analysis?

A

Hang a string with something heavy attached to the end from the inion. This should create a straight vertical line from which the scoliotic curve can be measured/seen.

36
Q

What curves can the plumb line analysis (hung from the inion) measure?

A

Completely compensated curve - plumb line falls at mid-sacrum & mid-heel points
Partially compensated curve - plumb line is off mid-sacrum, but falls at mid-heel point
Decompensated/collapsed curve - plumb line off mid-sacrum and off mid-heel point

37
Q

What are common etiologies of structural scoliosis?

A

Neurologic
Congenital
Connective tissue diseases
Idiopathic

38
Q

Neurologic etiologies are either __________ or ____________.

A

reversible; irreversible

39
Q

A reversible neurologic etiology responds to what?

A

Surgical intervention

40
Q

An irreversible neurologic etiology usually involves what?

A

Muscle weakness

41
Q

Reversible neurologic etiologies include?

A

Chiari malformations, neurofibromatosis, and tethered spinal cord

42
Q

Irreversible neurologic etiologies include?

A

Cerebral palsy and muscular dystrophy (myopathic)

43
Q

What are chiari malformations?

A

Congenital deformities of the brain stem and upper spinal cord (e.g. syringomyelia). Surgical decompression of the malformation results in correction of the scoliosis.

44
Q

What should you do with all new structural scoliosis patients?

A

MUST DO MRI (craniocervical) on all new structural scoliosis patients.

45
Q

What is neurofibromatosis?

A

Benign tumors which may impinge on the spinal cord or nerve roots. Removal of these tumors results in correction of the scoliosis.

46
Q

What happens with irreversible neurologic etiologies?

A

Severe neurologic or myopathic disease creates a spine that cannot support itself. Such spines collapse into bizarre scoliotic patterns. Surgical fusion of the spine is the treatment of choice.

47
Q

What is a condition that causes neurologic scoliosis?

A

Morquio disease

48
Q

How does paralytic scoliosis present?

A

Paralysis of paraspinal muscles; if you lift the head/shoulders, the curve straightens out (no muscle tone).

49
Q

What can cause both neurologic and paralytic scoliosis?

A

Polio

50
Q

What is a cause of congenital scoliosis?

A

Hemivertebrae

51
Q

What are connective tissue diseases that can cause scoliosis?

A

Marfan syndrome and Ehlers-Danlos syndrome

52
Q

What is the likely origin of idiopathic scoliosis?

A

Most likely genetic; it has polygenic expression. Now have a genetic screening test - Scoliscore - that, when used in patients aged 9-13 years who have curves less than 25 degrees, can predict the likelihood that the curve will progress to 40 degrees or greater.

53
Q

Name some facts about scoliosis.

A

Affects 2-3% of the population
0.5% of all curves ever exceed 25 degrees
Possible X-linked genetic etiology; 1st degree relatives have a 10% prevalence of scoliosis
Women predominate in adolescent curves

54
Q

What is one way that you can distinguish between a double major curve and a simple C-shaped curve with a compensatory curve.

A

Idiopathic scolioses tend to be quite rigid; the compensatory curve will usually reverse with side bending while the primary curve will not.

55
Q

Will you see a worse rib hump with a more minor or major scoliotic curve?

A

Minor

56
Q

What are the treatment options for idiopathic scoliosis?

A 
OMT
Exercise
Bracing
Traction
Implantable paraspinal electrical stimulator
Surgical fusion
57
Q

How does OMT treat the scoliotic curve?

A

Removes coexisting somatic dysfunction that may render a scoliosis symptomatic
May halt progression of mild curves (per case reporting)
Can aid in recompensating a decompensated scoliosis
Helps maintain mobility of spine and rib cage (better mobility = better outcome of bracing or surgery)
Improves respiratory and cardiac function in patients with severe curves

58
Q

How does exercise treat scoliosis?

A

No evidence that exercise changes the course of idiopathic scoliosis, but it does aid in maintaining mobility of the spine, and better mobility leads to better outcome of bracing or surgery.

59
Q

How does traction treat scoliosis?

A

Maintains mobility of the spine, but does not change the natural course of idiopathic scoliosis. Improves outcome of bracing or surgery.

60
Q

How does bracing treat scoliosis?

A

No brace has been shown to correct an idiopathic scoliosis. However, braces are successful at halting the progression of a significant number of curves. The most common brace in use is the Milwaukee Brace, as well as variations of it.

61
Q

Describe the Milwaukee Brace.

A

Maintains continuous traction between pelvis and occiput. Not very comfortable - hard to eat, get headaches, etc. Wearing the brace can be psychologically difficult as well, especially during formative years.

62
Q

What is a new style of bracing?

A

TLSO - Thoraco LumboSacral Orthosis - underarm bracing.

63
Q

How long must the brace be worn?

A

Different bracing regimens require the brace to be worn a minimum of 12 hours per day (while erect), up to a maximum of 23 hours per day (most common).

64
Q

How does the implantable paraspinal muscle electrical stimulator work?

A

Surgically implanted and turned on during sleep. The device gently pulses to contract PVMs. May be used instead of bracing. Can only be used for mild curves in the same range as the use of braces.

65
Q

In a study of girls aged 10-15 years who had 25-35 degree curves, success was defined as a progression of less than 6 degrees in 4 years. What was the success rate for bracing, electrical stimulation, and observation only?

A

Bracing - 74%
Electrical stimulation - 33%
Observation only - 34%

66
Q

Bracing trial: a multicenter, randomized trial comparing bracing with watchful waiting - BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial). Bracing prevented progression to surgical level of ____ degrees in ___% of treated patients. In the observation arm of the study, only ___% did not reach ____ degrees.

A

50; 72; 48; 50

67
Q

How is the end of bone growth determined?

A

Using the Risser scale: judge end of bone growth by the fusion of the iliac crest apophyses. Fusion progresses from ASIS to PSIS. Total excursion and fusion can take 12-36 months.

68
Q

At what age does skeletal maturity occur for females? Males?

A

16; 18

69
Q

When would you perform surgery on a scoliosis patient?

A

When bones are finished growing.

70
Q

What are 3 stages for determining skeletal maturation?

A

Iliac crest progressing posteromedially - vertebral growth plate in formation.
Excursion complete - growth plate complete but not united.
Crest fused with ilium; maturation complete - growth plate united to vertebral body; maturation complete.

71
Q

How many grades are there to the Risser Sign, and at what grade would you do surgery?

A

5 grades - do surgery at 4 or 5 (complete fusion at grade 5). Exceptions are granted for patients with extreme curves that significantly compromise cardiopulmonary function.

72
Q

What is the age at which girls are at stages 1 & 5 for the Risser Scale? Boys?

A

Girls: 13.8 at stage 1; 16.1 at stage 5
Boys: 15.2 at stage 1; 18.0 at stage 5

73
Q

When would you do surgical correction for scoliosis?

A

Not done until patient reaches skeletal maturity, unless there is rapid progression of the curve. Often requires a midline incision the length of the spine. Periosteum is scraped off the bone to remove muscles. Cadaveric bone is used to create a total spinal fusion.

74
Q

How is the surgery performed for a patient under 10 years of age? Over 10 years of age?

A

Under age 10: instrumentation is done without bony fusion to allow for revision. Over age 10: internal metallic fixation devices are used in combination with bony fusion.

75
Q

What is a consequence of a fused lumbar spine?

A

Hypermobility; hips are overused, so they wear out. However, you can replace hips, so this is “ok” (can’t replace the spine).

76
Q

What percentage of patients will require subsequent surgical revisions?

A

3-10%

77
Q

What is the Harrington Rod placement?

A

Straight, fluted rod with extensions along the side is used to straighten the scoliotic curve; use a ratchet device to straighten. Problem - have to do bony fusion, but even this can’t always prevent breaks.

78
Q

Why might you use 2 Harrington rods?

A

Smaller rod could be used as compression to squeeze the side together (usually used for rib deformity correction).

79
Q

What do pedical screws and a contoured rod allow for when used for surgical intervention?

A

They allow for preservation of sagittal spinal curves, thus avoiding the symptomatology associated with flat back syndrome.

OMM M1T2 test 1 (14 decks)

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