paralytic and postural scoliosis
TRANSCRIPT
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MODERATOR:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSC (HON)
Director & HODPRESENTOR:DR.THOUSEEF.A.MAJEED
paralytic & Postural Scoliosis
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INTRODUCTION
• “Scoliosis” - Greek word meaning “crooked.”
• It is a lateral curvature of the spine in upright position.
• The Scoliosis Research Society has defined scoliosis
as a lateral curvature of the spine greater than 10
degrees as measured using the Cobb method on a
standing radiograph.
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• Triplanar deformity of lordosis,
rotation & lateral wedging of
vertebrae.
• It produces body
disfigurement.
• When deformity is extreme it
compresses viscera and reduces
life expectancy of the patient.
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“Normal” alignment
• Spinous processes all line up in a
straight line over the sacrum
Scoliosis is a combination of
• Angular displacement
• Lateral displacement
Spinal Biomechanics
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Lateral displacement • Angular displacement
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• Paralytic scoliosis is defined as the increased
lateral curvature of the spine due to paralysis of
spinal muscles.
PARALYTIC SCOLIOSIS
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• Curve is long, convex towards the side with weaker muscles
( spinal, abdominal or intercostal) & at first mobile
• Rapid progression of the curve due to asymmetrical
paralysis.
• Loss of stability & balance which makes sitting difficult in
severe cases
• Loss of sensibility causes pressure ulceration
• Respiratory insufficiency
• Pelvic obliquity
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Classification
• NEUROPATHIC • MYOPATHICNeuropathic• Poliomyelitis Lower motor neuron• Traumatic• Spinal muscle atrophy• Dysautonomia
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• Cerebral palsy
• Friedreich ataxia
• Charcot Marie Tooth
• Syringomyelia
• Spinal cord tumour
• Spinal cord trauma
Upper motor neuron
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MYOPATHIC
• Arthrogryposis
• Muscular dystrophys
• Congenital hypotonia
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CURVE PATTERNS IN PARALYTIC SCOLIOSIS
• Thoracic • Thoraco-lumbar • Lumbar• Combined thoracic and lumbar • The side towards which the
convexity of the curve is directed is designated as Right or Left.
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• The curve may take some years to develop
• It gives a paraylitic curve with long, convex
towards the side with weaker muscles.
(spinal,abdominal or intercostal)
• Pelvic oblquity develops due to muscle
imbalance .
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• Loss of muscle strength or voluntary muscle
control and loss of sensory abilities in the
flexible and rapidly growing spinal column
results in these curve development.
• Rapid progression in the curvature (12-16
years)
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• Deformity is usually the presenting symptom
• Pain is rare complaint
• long C-shaped curve
• Rib hump or abnormal para spinal muscular prominence
indicates spinal rotation
• Rib hump leads to asymmetry of trunk called angle
trunk rotation (ATR) .
CLINICAL FEATURES
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TREATMENT OF PARALYTIC SCOLIOSIS
Conservative
• Conservative is preferred initially up to 10 years
of age.
• Fitting a suitable sitting support.
• Halo femoral traction
• Milwaukee brace
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Surgical treatment
• Indicated after 10 years
• Failed conservative treatment
• Curve is progressing inspite of conservative treatment
• High cervico dorsal curves
• Patients with cardiopulmonary insufficiency due to
scoliosis
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• Stabilization of entire paralysed segment by
combined anterior & posterior fusion.
o When paralysis of the trunk is extensive -fusion is
best done in stages.(T1-L3 or L4).
o Pelvis is included in fusion if pelvis is tilted and
forms a component part of the primary curve
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• The treatment of scoliosis with pelvic obliquity
varies according to the location.
1. Distal to the iliac crest
2. Proximal to the iliac crest
3. Above and below the crest
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Distal to the iliac crest
Hip flexion-abduction contracture
• Stage I :Surgical release of flexion abduction
contracture.
• Stage II :Scoliosis is then treated as an
independent problem
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Proximal to the iliac crest
• Correct obliquity and scoliosis together.
• Fusion to maintain correction .
• Fusion must extend to the sacrum
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Above and below the crest
• Both deforming elements must be
corrected(obliquity and scoliosis)
• Fusion must include sacrum
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Scoliosis in polio myelitis• Asymmetrical paralysis of paraspinal muscles.
• May affect any part of the spine
• 5% of poliomyelitic patients affect scoliosis.
• The muscle imbalance is the cause for developing
scoliosis.
• When paralysis is extreme and symmetrical ,
scoliosis may not develop
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Spinal curvature is divided into two types
• 1.Convexity of curve towards stronger muscle
groups (eg:the ilio psoas, the sacrospinalis and the
quadratus lumborum)
• 2.Concavity towards stronger muscle groups.
(eg:the abdominalis ,the sacro spinalis and the
quadratus lumborum)
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• Contracture of the pelvi trochanteric muscles
and the iliotibial band with resultant pelvic
obliquity deviates the spine towards that side.
• Neurological element also result in structural
changes in the spine.
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• Long C type of curve
• Appearance of curve with in 10 years of age and progress in
adulthood.
• Rapid progression in the curvature(12-16years)
• 15° or more occurring before the age of 11 should be
viewed with a high index of suspicion for underlying intra
spinal pathology.
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3 Major types of poliomyelitic scoliosis
• High Cervicodorsal kyphoscoliosis
• Long Dorsolumbar scoilosis
• Lumbar Scoliosis
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Treatment for poliomyelitic scoliosis
• Conservative treatment
• Surgical treatment
Conservative treatment
• Prolonged recumbancy 6 months in paralysis
of trunk and abdominal muscles.
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• Lying on a concave frame favours weak
abdominalis muscle
• Spine should be evaluated every 3months by
standing radiographs.
• Postpoliomyelitic scolotic brace
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• On begining of ambulation ,if asymmetry of
abdominalis and hip muscles exists then the use of
crutches with a tripod gait is necessary
• Halo –femoral traction should be avoided because it
may produce additional osteoporosis
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Surgical indication in poliomyelitic scoliosis
• Collapsing spinal deformity
• Spinal deformity does not respond to nonoperative
treatment.
• Reduction of cardio respiratory function .
• Back pain and loss of sitting balance with increased
pelvic obliquity
•
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Surgical treatment for poliomyelitic scoliosis
• Early fusion should de avoided
• Many paralytic curves becomes stable and static
and require no fusion.
• Pelvic obliquity = Iliotibial band resection
• Abdominal & Quadratus lumborum = Fascial
transplants.
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For high cervico thoracic curves
• Scapular elevator muscles, two strips of fascia are
attached to the scapular spine
• one strip to the cervical muscles at the apex of the
curve on the concave side.
• The other strip to the spinous process of the first
thoracic vertebra
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Rhomboids and levator scapulae paralysis
• These muscles normally pull the scapula upward
and inward and exert tension on the cervical and
upper 4 thoracic vertebrae.
• Paralysis causes the pull of spine to opposite side.
• Facial transplants are attatched to the vertebral
border of scapula and into the spinal muscles & the
latismus dorsi
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• Long fusion is necessary to result in a
balanced spine.
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CEREBRAL PALSY SCOLIOSIS
• Most often thoraco lumbar curve
• Pelvic obliquity & hip contracture present
• Progressive curve of any degree depends on
the degree of neuromuscular inolvemnt.
• Normal mortality
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Clinical features
• Thoracolumbar curve is common
• Unlike idiopathic scoliosis scoliosis produced
by cerebral palsy may be painful.
• Sitting may be more difficult due to increase in
pelvic obliquity.
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Goals of scoliosis treatent in Cerebral Palsy ----Bonnette etal
• Improvement in assisted sitting.• Relieve the pain from back and hip.• Increased independence because decreased
need for assistance.• Improvement in upper extremity function and
table top up activities
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Classification
• Lonstein and Akbarnia classified cerebral palsy into two groups.
• Group I curves
• Group II curves
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Group I Curve
• Double curves
• Both thoracic and lumbar components
• Similar to the curves of idiopathic scoliosis.
• Commonly occurs in ambulatory patients with
mental retardation.
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Group II
• Thoracolumbar curves that extend to the
sacrum with marked pelvic obliquity
• Patients with this curve are non ambulatory
with spastic quadriplegia
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• Best managed by early recognition and control of
the curve before the deformity becomes severe.
• Seating is the most common non-operative form .
• The orthoses of choice is a total contact
thoracolumbosacral orthosis (TLSO) Or soft boston
orthosis.
Treatmentof Cerebral palsy Scoliosis
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• Curve >50 degree requires surgical correction.
For severe lumbar and thoraco lumbar curves
• Stage I :Anterior fusion with Dweyer’s
instrumentation over apical area.
• Stage II : After 2 weeks
• Posterior fusion with Harington Rods etending to
the sacrum.
• Upper limit of fusion should be above T4
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Surgical Complications of cerebral palsy scoliosis
• Increased risk of infection
• Pulmonary complications (cannot co operate
in deep breathing ).
• Kyphosis cephalad to the upper limit of
fusiona.
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Scoliosis in Arthrogryposis congenita
• Syndrome of persistent joint contractures at birth
• Scoliosis may develop from birth itself.
• Common pattern is thoracolumbar curve.
• Associated with pelvic obliquity and lumbar
hyperlordosis.
• Curves are progressing according to age and
becomes rigid and fixed
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Classification
• Subtype I:Myopathic- characterised by muscle
changes
• Subtype II: Neuropathic-anterior horn cells are absent
or reduced in cervical, thoracic and lumbosacral
segments .
• Subtype III: joint fibrosis and contractures alone.
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Treatment of arthrogrypotic scoliosis
• Brace treatment rarely successful and should be used
in patient with small flexible curve and curve of less
than 30 degree.
• Pelvic obliquity can be treated by release of
contractures in the hip area .
• If the scoliosis not corrected by release of
contractures spinal fusion to the sacrum is necessary
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Surgeries for arthrogrypostic scoliosis
• Harrington instrumentation and posterior fusion.
• Combined anterior and posterior spinal arthrodesis.
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FRIED RICH ATAXIA• Recessively inherited condition characterised by spinocerebellar
degeneration
• Onset 6-20 years of age
Characterised by
• Ataxic gait
• Dysarthria
• Muscle weakness
• Lack of deep tendon reflexes
• Decreased proprioception
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Secondary symptoms include • Pes cavus• Scoliosis• Cardiomyopathy• The most common pattern is double structural
thoracic and lumbar curves.• Pelvic obliquity may present.
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Treatment for spinal muscle atrophyOrthotic treatment :
• skeletally immature patient with 20 degree curve.
• TLSO(thoraco lumbo sacral orthosis) .
• Chest wall deformities are contraindication for orthotic
treatment.
Surgical treatment
• by posterior spinal fusion with instrumentation and
bone grafting.
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• For a fixed lumbar curve with pelvic obliquity
anterior release and fusion may be needed in
addition to posterior instrumentation.
• After surgery ventilator support may be
necessary due to pulmonary complications.
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FAMILIAL DYSAUTONOMIA• Rare autosomal recessive disorder• Commonly seen in jewish chidrenCharacterised by • Overflow of tears• Sweating • Vasomotor instability– hypothermia• Dysrthria• Dysphagia • Motor incordination• Scoliosis and Kyphosis
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• Progressive type of curve• In this patients early death is due to
kyphoscoliotic cardiopulmonary decompensation.
• Scoliosis can be conservatively managed by Milwaukee brace.
• Surgery :Posterior spinal fusion with instrumentation
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POSTURAL SCOLIOSIS (MOBILE SCOLIOSIS)
• The scoliosis deformity is secondary to some
condition outside the spine .(short leg ,pelvic tilt)
• When the patient sits the curve disappears. (non
structural)
• Occurs in late years of first decade of life
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Causes for postural scoliosis
• Short leg
• Pelvic tilt
• Local muscle spasm with a prolapsed lumbar disc
• Sciatica-Sciatic Scoliosis.
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Treatment • Depends on the degree of functional disability.
• Mild curves may require no treatment
• Moderate curve with spinal stability are managed as same as
idiopathic scoliosis
• Severe curves with pelvic obliquity and loss of sitting
balance managed by proper sitting support.
• If this fails operative treatment is indicated.
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• Surgery involves the stabilization of the entire paralysed
segment by combined anterior and posterior
instrumentation and fusion.