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Case Study XIV

Case Study XIV. Sean Hester, SPT & Megan Legault, SPT. Case Study XIV. Female- Emma 12 y/o Pt conservatively managed with Milwaukee brace but has been unsuccessful in managing her pathology surgeon considering Cotrel-Dubousset procedure. Examination. decreased trunk flexibility

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Case Study XIV

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  1. Case Study XIV Sean Hester, SPT & Megan Legault, SPT

  2. Case Study XIV • Female- Emma • 12 y/o • Pt conservatively managed with Milwaukee brace but has been unsuccessful in managing her pathology • surgeon considering Cotrel-Dubousset procedure

  3. Examination • decreased trunk flexibility • Impaired postural alignment www.scoliosis-australia.org

  4. Examination9 Adam’s forward bend test: observed asymmetry in contour of back (rib hump) orthoinfo.aaos.org

  5. Examination X-rays from MD show thoracic curve= ~63° using the Cobb Method Measurement uses standard posteroanterior standing radiograph of the spine. Cobb Method Example www.spineuniverse.com

  6. Exam Neuro Exam All dermatomes, myotomes and reflexes WNL No abnormal neuro findings Vital Signs RR 24 bpm BP 118/75 HR 60 bpm

  7. Diagnosis Adolescent Idiopathic Scoliosis www.keyboard-culture-scoliosis.com

  8. Milwaukee brace: used in tx of adolsecent idiopathic scoliosis since 1954 to prevent further progression of the curve and need for sx.5 www.scoliosisjournal.com/content/2/1/19/figure/F2

  9. Red Flags9 For Secondary cause of scoliosis (non-idiopathic) Possible spinal cord pathology Severely pnful scoliosis Marked stiffness Deviation to one side during Adam’s forward bend test Rapid progression of curve (in previously stable curve) Rapid progression of curve (after skeletal maturity) Abnormal neuro findings L thoracic curves (90% are R thoracic curves) b/b dysfunction

  10. Non-Idiopathic Scoliosis10

  11. Etiology6 Current idea that there is a defect of central control or processing by the CNS that effects the growing spine, and that susceptibility to deformation varies by individual. May be alterations in melatonin production, with direct or indirect consequences on growth mechanisms. We know there is a complex, multi-factorial process involved; however, no true etiology is known.

  12. Prevalence9 • Present in 2-4% of children between the ages of 10-16. • 10 percent of these children have curvature great enough to require medical intervention. • Male to female ratio with a curvature of <10° is equal, but with a curve of >30° ratio moves to one male per every 10 females.

  13. Characteristics Definition: Characterized by having a greater than 10° lateral curvature on a standing radiograph, and most have curvature to the right. Curves < 30° are unlikely to progress. Curves 30-50° progress 10-15° on average in a lifetime. Curves > 50° at maturity progress at 1 degree a year. Life threatening effects on pulmonary function occur at around a 100° curve.

  14. Characteristics7 • Indications for surgery • Curve exceeding 45° to 50° by Cobb’s method • 1. curves > 50° progress after skeletal maturity • 2. curves > 60° cause loss of pulmonary function • 3. larger the curve progression, the harder it is to tx with sx

  15. Likelihood of Progression9 • The main risk factors for curve progression are having a large curve magnitude at the time of diagnosis, skeletal immaturity, and being of the female gender. • Skeletal growth potential (the big factor) is measured using Tanner staging and Risser grading to determine risk of progression.

  16. Risser Grading • This grades the progress of bony fusion of the iliac apophysis to determine skeletal maturity. • Grade 1- up to 25% ossification. • Grade 2- 26-50% • Grade 3- 51-75% • Grade 4- 76-100% • Grade 5- complete fusion.

  17. Risk of Progression

  18. NCMRR Model

  19. APTA Practice Patterns 4B: Impaired posture 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgical Procedures 6E: Impaired Ventilation and Respiratory/Gas Exchange Associated With Ventilatory Pump Dysfunction or Failure

  20. Prognosis1,10 Complications can include: cosmetic deformity & major disability  pn, respiratory insufficiency, or right-sided heart failure, pyschological effects Spinal surgery with instrumentation corrects a large part of deformity and prevents further progression of curve and need for post operative brace

  21. Prognosis1 Most with AIS live functional and normal lives Mortality rate similar to general pop. “The rate of intermittent back pn in people with curves of modest severity, 40° to 50°, is the same as the general population.”

  22. Prognosis Fair- without surgical intervention, respiratory function compromised 2° curve progression Good- with surgical intervention

  23. Goals LTG- Pt. to increase trunk ext. STR to 4/5 in 4 weeks for better recovery after surgery. STG- Pt. to increase trunk ext. STR to 3+/5 in 2 weeks. LTG- Pt. to hold TA 10sec. X 10 supine in 2 weeks for increased support after surgery. STG- Pt. to hold TA 5 sec. x 10 quadraped in 1 week.

  24. The Milwaukee Brace for the Treatment of Adolescent Idiopathic Scoliosis5 Lonstein JE, Winter RB. JB&JS 1994 • A review of 1020 pts • Purpose: to determine if utilization of Milwaukee Brace changes the natural hx of AIS • ~13.5 y/o managed for AIS with Milwaukee Brace between Jan 1954-Dec 1979 • Review of medical records and roentgenograms (measured using Cobb Method)

  25. The Milwaukee Brace for the Treatment of Adolescent Idiopathic Scoliosis5 Lonstein JE, Winter RB. JB&JS 1994 • Pts wore brace ~20-24 hrs/day until weaned off (at end of growth) or until sx if needed. • Pts allowed to remove during bathing, swimming, gymnastics, football and ice hockey • Pts seen every 3-4 mos. for brace eval & roentgenograms

  26. The Milwaukee Brace for the Treatment of Adolescent Idiopathic Scoliosis5 Lonstein JE, Winter RB. JB&JS 1994 • Rate of failure- measured by curve progression and need for sx. • Failure- if curve increased by >5º or surgical intervention necessary • Findings: lower rate of failure in pts treated with brace compared to previous study of pts who received no brace but were followed for progression (curves between 20º-39º • Researchers suggest treating adolescents immediately with brace rather than after progression when curve >25º +Risser sign = 0.

  27. Intervention5 DON’T give up Milwaukee Brace! It has been shown that though the brace isn’t stopping the progression, the progression will be faster in immature adolescents that aren’t in the brace. Increase trunk flex/ext STR pre-sx PT edu on sx intervention

  28. Cotrel-Dubousset Instrumentation3 • This technique attempts to achieve 3-dimensional correction of scoliosis, maintain lumbar lordosis, create thoracic kyphosis, and avoid the need for post op casting. • Also aims to avoid need of postsurgical cast or brace orthopedics.seattlechildrens.org

  29. Cotrel-Dubousset Cont. • Used Since 1984 • Provides bilateral segmental fixation of the spine. • Post op thoracic curves have been shown to average a 50 percent correction with the tilt of the most caudal instrumented vertebrae improved by 65 percent. • Thoracic kyphosis is shown to improve, with lumbar lordosis brought significantly close to normal. www.scoliosis.org/.../instrumentationsystems.php

  30. Cotrel-Dubousset Cont.8,2 • Evidence shows that there is a definite increase in pulmonary function after a correction surgery. • The Cotrel-Dubousset procedure (a posterior approach) was studied against three different anterior approach, and showed better pulmonary function at a 5 year follow up. • It was stated that “chest cage preservation is recommended to maximize pulmonary function testing after surgical treatment.”

  31. Embedded Issue10 The child has had unusual scarring issues all of her life. This procedure will make her more susceptible to abnormal scarring due to the dynamic mechanical skin tension that lies in the back. www.flickr.com

  32. Scar Management10 • Important to manage scar correctly to prevent it from causing further impairments. • The University of Chicago Scar Clinic has given a five stop protocol. • Step 1- Scar eval and classification • Step 2- Control inflammation with anti-inflammatory drug • Step 3- Accelerate scar maturation with an occlusive barrier such as hydrogel sheeting • Step 4- Stim scar degradation with calcium antagonist • Step 5- Evaluate progress

  33. Body Image4,9 “…significant psychologic illness has been found in up to 19% of females who have curves >40° as adults.” poorer perception of body image in adolescents with scoliosis vs. control group without scoliosis. Problems with psychological and social development. Quality of life affected by presence & tx (including bracing) of AIS

  34. Emma www.geocities.com http://www.youtube.com/watch?v=INizPSEF0-0&feature=related

  35. References 1. Campbell SK, Linden DV, Palisano RJ. Idiopathic Scoliosis. Physical Therapy for Children. 2006: 340-347. 2. Kim Y, Lenke L, et al. Pulmonary Function in Adolescent Idiopathic Scoliosis Relative to the Surgical Procedure. J Bone Joint Surg. 2005;87(7):1534-1541 3. Lenke LG, Bridwell KH, Baldus C et al. Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis. J Bone Joint Surg Am.1992;74(7):1056-1067. 4. Lenssinck MM, Frijlink AC, Berger MY et al. Effect of Bracing and Other Conservative Interventions in the Treatment of Idiopathic Scoliosis in Adolescents: A Systematic Review of Clinical Trials. Physical therapy. 2005;85(12):1329-1339. 5. Lonstein JE, Winter RB. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of one thousand and twenty patients. J Bone Joint Surg Am. 1994;76(8):1207-1221 6. Lowe T, Edgar M, et al. Etiology of Idiopathic Scoliosis: Current Trends in Research. J Bone Joint Surg Am. 82(8):1157-1168 7. Maruyama T, Takeshita K. Surgery for Idiopathic Scoliosis: Currently Applied Techniques. Clincal Medicine: Pediatrics. 2009;3:39-44. 8. Newton P, Perry A, et al. Predictors of Change in Postoperative Pulmonary Function in Adolescent Idiopathic Scoliosis: A Prospective Study of 254 Patients. Spine. 2007;32(17):1875-1882 9. Reamy BV, Slakey JB. Adolescent Idiopathic Scoliosis: Review and Current Concepts. American Family Physician. 2001;64(5):111-116. 10. Roseborough I, Grevious M, et al. Prevention and Treatment of Excessive Dermal Scarring. Journal of the National Medical Ass. 2004;96(1):108-116

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