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
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/
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.
Today’s Plan
• Pathology• Measuring Scoliosis• Treating Scoliosis• Differences when not idiopathic• Congenital
• Handout– All references– Crib sheet
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
Clinical Assessment
• History– deformity– pain– general health– development &
maturity– family history
• Examination– general (diagnosis)– specific (deformity)
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
Examination of the Back
Quantifying Spinal Deformity
C7
T3
T5
T7
T9
T11
L1
L3
L4
Sacrum
Surface and Spine Measures
Bunnell WP.JBJS [Am] 1984; 66-A: 1381-7.
Clinical and Surface Topography
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.
Classification - Type of curve - OLD
Classification - Type of curve
Lenke
Spinal Growth
Risser Sign
Spinal Height Spinal Height Gain (cm/yr)Gain (cm/yr)
AgeAge
Spinal Growth Velocity
GROWTH VELOCITY OF THE SPINE
98o113o
3 months later
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
The Spinal - Rib Cage Connection
Nash and Moe. A Study of Vertebral Rotation.JBJS [Am] 1969; 51-A: 223-9.
Objectives of Surgery
• Cosmesis– Prevention of curve progression– Correction of curve
• Reduce the cardio-pulmonary consequences of scoliosis
• Avoid neurological complications
Posterior Spinal SurgeryCase ♀ - AIS
66%
Pedicle Screw Constructs- Idiopathic Scoliosis
08.03.200715yrs 5mth
15.11.200615yrs 1mth
58 o
23 o
45 o
23 o
Anterior Release & Costoplasty
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.
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? ? ? ?
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.
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.
Syrinx – Case ♀
• 13y10m
• Hx fall off trampoline 2yrs
• Left mid thoracic back pain, no radiation.
• Neurology– Symm. Absent
abdominal reflexes
Syrinx – Case ♀
Syrinx – Case ♀Posterior decompression
by Miss Lynn Myles16/09/2009
“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.
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
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
Spina Bifida - Case ♀
27.07.2007no97
Spina Bifida - Case ♀26.07.20078yrs 9mth
130 o
31.07.20078yrs 9mth
50 o
no97
Spina Bifida - Case ♀Outcome
12.06.20078yrs 8m
11.12.20079yrs 2m
NO brace
Brace
no97
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
Congenital
Congenital
“Congenital deformities of the spine”
McMaster MJ
J R Coll Surg Edinb 2002;47:p475-80
Congenital - Case ♂
Discussion / Comments / Questions
• …
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