Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital
Jaipur
Scoliosis - Basics Dr Lalit Sharma Spine Surgeon Narayana
Multispeciality Hospital Jaipur What is scoliosis Demographics
& Etiology Clinical Evaluation Radiological Evaluation
Treatment Scoliosis Abnormal lateral curvature of spine Deformity
in the coronal plane 3 Dimensional Deformity
Coronal Plane Sagittal Plane Axial Plane 3 Dimentional Deformity
Demographics Occurs in 1-3% of population below the age of 16
years.
0.1% have a curve greater than 40 degrees. Girls are more affected
than boys. Those with a curve of more than 30 degrees are generally
girls, outnumbering boys by 10:1. Types of Scoliosis Congenital
Neuromuscular Syndromic Idiopathic
Cerebral palsy / PPRP Syndromic Marfans syndrome Neurofibromatosis
Idiopathic 80% - Most common Degenerative Idiopathic -
Classification
Infantile:0-3 years old (.5%) Juvenile: years old (10.5%)
Adolescent: years old (89%) Early Onset : 5 years or less Late
Onset:more than 5 years Anatomy All bony elements are altered Discs
are wedged as well
Vertebra are wedge shaped Poorly Developed Concave side Pedicles
rotated Discs are wedged as well Etiological Theories Genetic
Tissue deficiencies Growth abnormalities
Central nervous system alteration Genetic Strongly Familial 11%
incidence in first relatives of patients
Normal incidence < 3% Monozygote twins more common Gene
identified Chromosome 3p26. LBX1, DSCAM gene Tissue Deficiencies
Marfans syndrome deficient fibrillin
Osteopenia noted in girls Elevated calmodulin Involved in
contractile properties thru actin & myosin Elevated in
platelets No consistent findings to date Growth Abnormality
Asymmetrical vertebral growth
Hueter-Volkman effect is suppression of growth on concave side
Hypokyphosis during growth spurt No increased incidence with growth
hormone No initiating factor identified Central Nervous
System
Different size cerebral cortices Associated Syrinx, Low lying cord,
Arnold Chiari Malformation Functional Spinal Cord Tethering
Deficient melatonin Chicken model Inconclusive in humans History
First noted and progression Family history
Affected sibling 7 times more frequent Affected parent 3 times more
frequent Recent growth history Sexual maturity Pain Fatigue pain
Post diagnostic pain Severe pain Physical Exam Iliac crest height
Shoulder height Arm trunk space
Leg length discrepancy Shoulder height Arm trunk space Scapular
position Trunk shift Neuro exam /Muscle charting Generalized
Features Marfans Inspection of skin Caf au lait spots Hair patch
Physical Examination:
Features suggestive of polio, neurofibromatosis, Von Reclinghausen
syndrome, Downs, Marfans, Hurlers syndrome, neural tube defects and
osteogenesis imperfecta. Forward protrusion of chest wall on
affected side. Increased flank creases on opposite side. Higher
ASIS and PSIS on concave side. Spinous process turned into concave
side. Forward Bend Test Adams sign Radiological Evaluation
PA & Lateral Whole Spine Standing Films Posterior to anterior
Decrease thyroid and breast exposure 3-7 fold AP Whole spine right
and left bending films lying down Traction X-rays Fulcrum Bend
X-rays Scoliosis Analyzing Curve
Structural and Non Structural Primary Curve and Secondary Curve End
vertebra Apex Cobbs Angle Stable zone Rotation Structural Curve
Position Independent Fixed deformity
Structural changes Primary Curve Structural Lateral Curvature with
Rotation
Recognized Clinically Measured Radiographically End Vertebra Most
tilted vertebra Last to show rotation of Spinous process Pedicle
width equal on each side Neutral Disc / Neutral Vertebra
Compensatory Curves Above and below the primary curve
In opposite direction to primary curve No fixed clinical rotation
Righting Reflex Measurement of Scoliosis Cobbs Angle Rotation
Spinous process rotates into concavity
Nash & Moe method - Pedicle position Stable Zone / Stable
Vertebra Nomenclature Cervical C1 to C6-7 Disc Cervicothoracic C7
to T1
Thoracic T1-2 Disc to T11-12 Disc Thoracolumbar T12 to L1 Lumbar
L1-2 Disc to L4-5 Disc Lumbosacral L5 and below T5 T9 Compansatory
Curve 760 L1 Skeletal Maturity History and Physical Exam
Triradiate cartilage fusion Risser sign Kings Classification
Double curve, both curve cross the midline, Lumbar curve larger ,
stifferthan the thoracic curve Double curve, both cross the midline
Thoracic curve larger, stifferthan the lumbar curves. Long thoracic
curve in which L5 is centered over sacrum but L4 tilts into long
thoracic curve Thoracic curve and T1 tilts to upper curve Thoracic
curve crosses midline andlumbar curve does not cross midline Lenke
Classification MRI Neurologic deficit Infantile and juvenile
curves
Spinal cord abnormality in younger children Infantile idiopathic
scoliosis 50% Juvenile 20% Who needs an MRI: A thoracic curve to
the left. Painful scoliosis.
Abnormal neurological findings. Untoward stiffness. Deviation to
one side during the bend test. Sudden rapid progression of a
previously stable curve. Treatment Natural History - Curve
Progression
Curves 30 to 50 degrees progress an average of 10 to 15 degrees
over a lifetime. Curves > 50 at maturity progress steadily at a
rate of 1 degree per year. Curves less than 30 at bone maturity are
unlikely to progress. Medical complications:
At 90 degrees or greater: increased potential for life threatening
effects on pulmonary function. Psychologic illness:seen in up to
19% of females with curves great than 40 degrees as adults. Natural
History Close relationship b/w increase in height & curve
progression Infantile rapid stage Juvenile slow stage Adolescent
rapid stage Mature slow stage Will the curve progress?
Three factors involved in progression Patients gender Females are
10 times more likely to have progression than males. Future growth
potential Skeletal Maturity Radiological / clinical Curve magnitude
at time of diagnosis The greater the growth potential and larger
the curve = more likely to progress Treatment Observation Bracing
Surgery Treatment RISSER CURVE Action 0 - 1 0 - 20 degrees 20 - 40
degrees
Observe Brace 2 - 3 degrees 30 40 degrees 0 - 3 0 - 4 40 50 degrees
50 degrees and higher Gray Surgery Bracing Orthotic braces - 74%
success rate at halting progression
Must be worn hours a day, but most pts are not compliant. Braces do
not correct scoliosis. Braces Bracing - Contraindications
Curves >450 Patient with noticeable Trunk shift Skeletally
mature adolescents Riser 4-5, 2 yrs post menarchal Curve apex above
T6 Excessive Thoracic Hypokyphosis < 200 Scoliosis - Surgery
Fusion gold standard
Creating a well balanced spine both Sagittal and Coronal plane
Instrumentation to maintain acceptable alignment Non-fusion options
- developmental Surgery Anterior Release Anterior
Instrumenation
Posterior Instrumentation Osteotomies - Pontes VCR Growth rods
Tests of flexibility of spine:
Adams forward bending test. Pushing the curve from convex side and
noting the correction. Lifting the patient up from head. X-rays -
Lateral bending / Fulcrum bend /Traction X-Rays Early Onset
Scoliosis Preserve as much growth potential as possible
Lung development Thoracic insufficiency syndrome Infantile
Treatment Must prove idiopathic 90% are left thoracic
3 female : 2 male 90% resolve spontaneously Predict progression by
RVAD < 20 degrees 83% resolve >20 degrees 84% progress
Congenital Scoliosis Vertebral malformation Rib Anomalies
Failure of formation Failure of segmentation Mixed Rib Anomalies
Spinal cord anomalies Urogenital / Cardiac Growing Rod Technique
Conclusion Scoliosis is common most are lordoscoliosis
Treatment depends on remaining growth potential, curve magniitude,
and sex Goal of treatment is to have a curve of < at Skeletal
Maturity Bracing Surgery Thank You Dr. Lalit Sharma
[email protected]
Consultant Spine Surgeon Narayana Hrudayalaya Hospital Jaipur
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