Consultant Spinal Surgeon Scottish National Spine Deformity Service Mr. Christopher I. Adams...
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Consultant Spinal SurgeonScottish National Spine Deformity Service
Mr. Christopher I. Adams
Scoliosis
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National Services Division- “Spinal Surgery”
Year Budget
£
Procedures
No.
2005 / 06 2,746,093 109
2006 / 07 2,912,821 145
2007 / 08 3,124,282 201
2008 / 09 ? 213
2009 / 10 ? 239
2010 / 11 4,910,000 (78%) 259 (137%)
www.nsd.scot.nhs.uk/publications/
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OCAP & FRCS (Tr and Orth) / ST3-6• Applied Clinical Knowledge Syllabus
– The Spine (Sec. 8-13)• “A basic knowledge of the surgery of spinal
deformity and tumours of the spine”. Competence level 3 = “Knows generally”.
– Paediatric Orthopaedic Surgery (Sec. 8-14)• “Knowledge of the neurological processes
involved in the production of deformity e.g. spina bifida, cerebral palsy and muscular dystrophy”. Competence level 3 = “Knows generally”.
• Clinical Procedures Syllabus– Thoracic Spine – Scoliosis correction –
posterior (Sec. 8-24)• Competence level 1 = “Has observed or
knows of”.• ST7-8, Competence level 3s = “Can manage
whole but may need assistance”.
• Interrupt at any time for questions…if you are thinking it, so are others.
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Today’s Plan
• Pathology• Measuring Scoliosis• Treating Scoliosis• Differences when not idiopathic• Congenital
• Handout– All references– Crib sheet
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Classification- Pathology
• Idiopathic (36%)
• Neuromuscular (21%)– Duchenne = 15 patients
• Congenital (10%)
West of Scotland clinics = 414pts• 2yr 10m, 26 Nov 2006 to 15 Sept 2009
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Clinical Assessment
• History– deformity– pain– general health– development &
maturity– family history
• Examination– general (diagnosis)– specific (deformity)
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General Examination
• General appearances– palate, ears, neck
• Skin– hair patches, skin dimples– scars– café au lait patches
• Joint laxity• Spinal dysraphism
– leg length, foot size inequality– foot deformities– asymmetric abdominal
reflexes
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Examination of the Back
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Quantifying Spinal Deformity
C7
T3
T5
T7
T9
T11
L1
L3
L4
Sacrum
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Surface and Spine Measures
Bunnell WP.JBJS [Am] 1984; 66-A: 1381-7.
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Clinical and Surface Topography
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Cobb Angle
θ
Outline for the Study of Scoliosis. Cobb, John R. (New York, New York, U.S.A.)American Academy Instructional Course Lectures 1948;Vol. 5: pg 266.
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Classification - Type of curve - OLD
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Classification - Type of curve
Lenke
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Spinal Growth
Risser Sign
Spinal Height Spinal Height Gain (cm/yr)Gain (cm/yr)
AgeAge
Spinal Growth Velocity
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GROWTH VELOCITY OF THE SPINE
98o113o
3 months later
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Scoliosis Progression
• Younger patients + large curves = great risk of progression
• Increased growth greater deformity
• Larger curves (> 50º) spontaneous buckling– Progression in
adulthood
130 cm
98o
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The Spinal - Rib Cage Connection
Nash and Moe. A Study of Vertebral Rotation.JBJS [Am] 1969; 51-A: 223-9.
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Objectives of Surgery
• Cosmesis– Prevention of curve progression– Correction of curve
• Reduce the cardio-pulmonary consequences of scoliosis
• Avoid neurological complications
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Posterior Spinal SurgeryCase ♀ - AIS
66%
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Pedicle Screw Constructs- Idiopathic Scoliosis
08.03.200715yrs 5mth
15.11.200615yrs 1mth
58 o
23 o
45 o
23 o
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Anterior Release & Costoplasty
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Intra-operative Monitoring- European Literature
• “Reviewing the literature on intraoperative monitoring makes it clear that application of a single method such as SEPs is not sufficient and that accounting for ascending and descending pathways of the spinal cord and nerve roots requires a multimodal approach.”
Current opinion and recommendations on multimodal IOM during spine surgeries. With Spinal Osteotomy. Sutter M, Delitis V, et al. (Multicentre)Eur Spine J 2007;16 (Supp2): pg S232-7.
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Intra-operative Monitoring- Literature
PaperYear
(pub)Deformity IOM +ve Neurology
Bridwell
n= 500pt
1987-97
(1998)Scoliosis ?
0.01% to 0.05%
SRS
n=670pt2001-4 Kyphosis ? 0.4%
Vitale
n=151pt
1999-05
(2010)Scoliosis 8% 1.3%
Lenke
n=42pt
2000-06
(2008)Kyphosis 21%
2.4%
(recovered)
U.K.
N=~1400? ? ? ?
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Syrinx
• Retrospective
• 1992 – 2005
• n = 13
• 11 yrs 1 mth– (3.6–16.4 years)
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland)Spine 2007;32 (21): pg 2327-33.
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Syrinx
• All fusion surgery
• No neurological deterioration
4vs= 4th ventriculo-arachnoid shunt
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland)Spine 2007;32 (21): pg 2327-33.
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Syrinx – Case ♀
• 13y10m
• Hx fall off trampoline 2yrs
• Left mid thoracic back pain, no radiation.
• Neurology– Symm. Absent
abdominal reflexes
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Syrinx – Case ♀
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Syrinx – Case ♀Posterior decompression
by Miss Lynn Myles16/09/2009
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“Superior Mesenteric Artery Syndrome in Paediatric Orthopaedic Patients”
• 1842 Rokitansky• N = 14 pts
– 1979 to 1987
• Presentation– Nausea– Intemittent and large
bile-stained vomiting– Between normal
appetite– Bowel sounds
present“SMA syndrome in paediatric ortho pts”Hutchinson DT and Bassett GS.from Ann Arbor, Michigan, USAClin Orth and Rel Research 1990 ;250:pg250-7.
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Changing Practice - Spina Bifida
• Only 10% no spinal deformity
JBJS Br 1980; 62-B: p54-8
• 6 to 12 degrees per yr
29.04.20082yrs 8mth196
05.02.200817yr 2m164
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Spina Bifida - Case ♀
• 8y8m• Pre-menarche• Braced since
18mths• Now tripod sitting• Motor level L1• VP shunt• Vesicostomy• PEG• Painless right hip
dislocation
• Picture
no97
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Spina Bifida - Case ♀
27.07.2007no97
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Spina Bifida - Case ♀26.07.20078yrs 9mth
130 o
31.07.20078yrs 9mth
50 o
no97
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Spina Bifida - Case ♀Outcome
12.06.20078yrs 8m
11.12.20079yrs 2m
NO brace
Brace
no97
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Surgical Objectives
• Preserve Neurology– bowel and bladder– sensation– use of legs
• Spinal and pelvic alignment– Level shoulders & pelvis– CoG over sacrum– Unaided sitting with stability
• Relationship to the hip
• Avoid other complications
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Congenital
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Congenital
“Congenital deformities of the spine”
McMaster MJ
J R Coll Surg Edinb 2002;47:p475-80
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Congenital - Case ♂
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Discussion / Comments / Questions
• …