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

• …