introduction to scoliosis - bangalore spine clinic · 1% of 1200 patients with congenital scoliosis...
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Introduction to scoliosis
Bone School @ Bangalore
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What is scoliosis?
Lateral curvature of the spine
> 10 degrees
Structural scoliosis
Non-structural scoliosis
Bone School @ Bangalore
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Structural Curve
Cobb measurement fails to correct past zero on supine maximal voluntary lateral side bending x-ray
Non-structural
Cobb measurement measurement corrects past zero on supine lateral side bending x-ray
Bone School @ Bangalore
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Bone School @ Bangalore
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Functional scoliosis – (usu. non-structural)
Limb length discrepancy
Sciatic scoliosis
Hysterical scoliosis - manifestation of a conversion reaction
Benign tumours – painful spasm – osteoid osteoma
Bone School @ Bangalore
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Sciatic scoliosis
Bone School @ Bangalore
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Screening for scoliosis – Adams test
Bone School @ Bangalore
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Bone School @ Bangalore
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Assessment of scoliosis- Coronal alignment
Bone School @ Bangalore
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Assessment - Sagittal alignment
Bone School @ Bangalore
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Classification of Scoliosis
Idiopathic
Congenital
Neuromuscular
Others
Bone School @ Bangalore
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Idiopathic scoliosis
Cobb (L) > /= 10º + rotation
Unknown etiology
Bone School @ Bangalore
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Types of idiopathic scoliosis
Infantile scoliosis - presenting from birth – 2+11
Juvenile scoliosis – 3yrs - 9+11
Adolescent scoliosis – 10yrs - 17+11
Adult scoliosis – 18 yrs and beyond
Bone School @ Bangalore
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Bone School @ Bangalore
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Absent abdominal reflex
Left thoracic scoliosis + Absent abdominal reflex
Bone School @ Bangalore
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Terminology
Cervical scoliosis - apex betwn C1 and C6-C7 disc
Thoracic - apex betwn T2 body - T11-T12 disc
T-L scoliosis - apex at T12, T12-L1 disc or L1
Lumbar - apex L1-L2 disc - L4-L5 disc
L-S scoliosis - apex - L5 or below
Bone School @ Bangalore
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Curve size > 40°
Curve rotation Moe grade 2 or more
Age ~ <10, pre-menarche
Skeletal maturity -Riser grade 0-2 -Open acetabular cartilage
Rapid Curve progression in
Bone School @ Bangalore
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Bone School @ Bangalore
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Curve progression in immature patients…
< 20° 22 % chance of progression
20-30° 68 % chance of progression
30-60° 90 % chance of progression
>60° 100 % chance of progression
Nachemson, Lonstein et al SRS 1982
Bone School @ Bangalore
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Treatment Options
Observation (but not neglect)
Orthosis – Brace
Operative
Bone School @ Bangalore
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Orthosis - Brace
Bone School @ Bangalore
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Guidelines – Not accurate
10-25 degrees – Observe / Brace
25-45 degrees – Brace (growing children)
> 50 degrees - Surgery
Bone School @ Bangalore
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Operative Treatment – Anterior
Bone School @ Bangalore
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Operative Treatment – Posterior
Bone School @ Bangalore
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Congenital Scoliosis
Bone School @ Bangalore
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Classification
Type I- Failure of formation
a) Hemivertebra
b) Wedged vertebra
Bone School @ Bangalore
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Classification
Type II- Failure of segmentation a) Block vertebrae
b) Unilateral unsegmented bar
Bone School @ Bangalore
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Classification
Type III- Mixed anomalies
Bone School @ Bangalore
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Associated anomalies
33% -Genito-urinary tract anomalies
25% -Klippel –Fiel syndrome
15% -Intraspinal anomalies
10% -Cardiovascular anomalies
Bone School @ Bangalore
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Bone School @ Bangalore
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Pattern of progression
50% -severe progression
25% - slow progression
25% - non progressive
Winter et al JBJS 1996
Bone School @ Bangalore
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Inheritance
Isolated hemivertebra - sporadic anomaly – no risk for siblings. Multiple anomalies - 5-10% risk for future siblings. Wynne-Davis J Med Gen 1975
1% of 1200 patients with congenital scoliosis has a known relative with the problem Winter RB Congenital deformities of the spine 1983
Bone School @ Bangalore
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Patients with multiple levels of bilateral failures of segmentation, with multiple fused ribs and missing segments have a positive family history.
Spondylothoracic dysplasia
Spondylocostal dysplasia
Spondylovertebral dysplasia
Jarcho-Levin Syndrome
Lonstein JE Principles and Techniques of Spine Surgery 1998
Inheritance
Bone School @ Bangalore
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Natural history of progression
McMaster and Ohtsuka JBJS (A)1982 Bone School @ Bangalore
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Natural history of congenital scoliosis
Bone School @ Bangalore
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Philosophy of surgical treatment
• Minimal concave growth potential. • Child may be taller if fusion is done earlier. • Better to be short and straight than shorter and crooked. • Limited role for bracing
Bone School @ Bangalore
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Surgical options
• Posterior fusion • Anterior and posterior fusion • Convex hemiepiphysiodesis • Hemivertebra excision • Growth rods / Shilla technique • Anterior stapling • VEPTR (vertical expandable prosthetic titanium rib) Bone School @ Bangalore
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Cobbs angle = 20 0 No coronal decompensation
Bone School @ Bangalore
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Bone School @ Bangalore