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Idiopathic Scoliosis

Idiopathic Scoliosis . dr n. med. Dariusz Mątewski. Lateral deviation of spine – postural deformity or scoliosis?.

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Idiopathic Scoliosis

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  1. Idiopathic Scoliosis dr n. med. Dariusz Mątewski

  2. Lateral deviation of spine – postural deformity or scoliosis? • Postural deformityof body (sensu stricte) is the clear deviation from the normal posture, which is possible actively and passively corrected orcan disappearduring normal growth of body

  3. Lateral deviation of spine – postural deformity or scoliosis? • The most frequent deformity of posture is a lateral curvature of the spine in the thoracolumbar section, mostly in left direction.

  4. Lateral deviation of spine – postural deformity or scoliosis? • Idiopathic scoliosis – developmental, three-plane deformity of spine and trunk of unknown etiology • Frontal plane – lateral deviation • Sagittal plane – disturbance of physiological lordosis and kyphosis • Horizontal plane – axial rotation of vertebras

  5. Scoliosis - definition • Scoliosis – spine curvature with Cobb angle > 10°

  6. Anatomy • All bony elements are altered • Vertebra are wedge shaped • Rib vertebral angle altered • Pedicles rotated • Discs are wedged as well

  7. Terminology • Named by apex • Cervical if between C2-C6 • Cervicothoracic if between C7-T1 • Thoracic if between T2-T11 • Thoracolumbar if between T12-L1 • Lumbar if between L2 and below • Primary vs secondary • Structural vs non-structural

  8. Types of Scoliosis • Congenital • Muscular • Duchenne atrophy • Neuromuscular • Cerebral palsy • neurofibromatosis • Syndrome related • Marfan’s syndrome • Idiopathic • 80% are this

  9. Etiological Theories • Genetic • Tissue deficiencies • Growth abnormalities • Central nervous system alteration

  10. Genetic • 11% incidence in first relatives of patients • Normal incidence < 3% • Monozygote twins more common • No gene identified to date

  11. Tissue Deficiencies • Marfan’s syndrome deficient fibrillin • Osteopenia noted in girls • Elevated calmodulin • Involved in contractile properties thru actin & myosin • Elevated in platelets • No consistent findings to date

  12. Growth Abnormality • Asymmetrical vertebral growth • Hueter-Volkman effect is suppression of growth on concave side • Hypokyphosis during growth spurt • No increased incidence with growth hormone • No initiating factor identified

  13. Central Nervous System • Different size cerebral cortices • Altered equilibrium • Primary or secondary • Deficient melatonin • Chicken model • Inconclusive in humans

  14. Classification • Infantile: 0-3 years old (.5%) • Juvenile: 4-11 years old (10.5%) • Adolescent: 10-17 years old (89%) • Adult: >18 years old

  15. Lenke classification • Typ 1- skolioza jednołukowa piersiowa (MT) • Typ 2- skolioza podwójna piersiowa (DT) • Typ 3- skolioza podwójna piersiowa i lędźwiowa z przewagą piersiowej (DM) • Typ 4- skolioza trójłukowa (TM) • Typ5- skolioza piersiowo-lędźwiowa jednołukowa albo lędźwiowa jednołukowa (TL/L) • Typ 6- skolioza podwójna z przewagą lędźwiowej lub piersiowo- lędźwiowej (TL/L structural MT)

  16. Gruca/Wiesflog classification • I grade scoliosis - <20° according to Cobb angle • I grade scoliosis - <20-40° according to Cobb angle • III grade skoliosis - >40° wg according to Cobb angle

  17. History • Family history • Affected sibling 7 times more frequent • Affected parent 3 times more frequent • Recent growth history • Sexual maturity • Pain • ‘Fatigue pain’ • Post diagnostic pain • ‘Severe pain’

  18. Physical Exam • Iliac crest height • Leg length discrepancy • Shoulder height • Arm trunk space • Scapular position • Trunk shift • Inspection of skin • Café au lait spots

  19. Forward Bend TestAdam’s sign

  20. Neurologic Exam • Observe gait • Hop test • Heel and toe walk • Reflexes

  21. Imaging • Plain x-rays • Need standing 36 inch cassette • Posterior to anterior • Decrease thyroid and breast exposure 3-7 fold • Note rotation • Measure deformity by Cobb method • Skeletal maturity

  22. Imaging

  23. Cobb Method

  24. Rotation • Spinous process rotates into concavity • Pedicle position

  25. Skeletal Maturity • Gruelich & Pyle atlas • Triradiate cartilage fusion • Risser sign

  26. MRI • Neurologic deficit • Infantile and juvenile curves • Spinal cord abnormality in younger children • Infantile idiopathic scoliosis 50% • Juvenile 20%

  27. Infantile Treatment • Must prove idiopathic • 90% are left thoracic • 3 female : 2 male • 90% resolve spontaneously • Predict progression by RVAD • < 20 degrees 83% resolve • >20 degrees 84% progress

  28. Juvenile Treatment • Younger onset likely to progress • >30 degree curve almost always progress • Some adolescent curves are missed juvenile

  29. Adolescent Treatment • Most curves <10 degrees • Boys = girls for these curves • Usually don’t progress • More sever curves (>30 degrees) • 8 girls : 1 boy • Predicting who will progress

  30. Risk for Progression • Younger onset • Skeletal age • Risser 0-1 at presentation 60-70% progress • Risser 3 only 10% risk • Menses starts after growth spurt • Female more likely than male • Curve pattern • Apex above T12 • Degree at presentation • 20-29 degrees 68% risk for progression • 30-59 degrees 90% risk for progression

  31. Treat or Not to Treat

  32. Natural History • If curve <30 degrees at maturity • No adult consequences • Unlikely to ever progress • Curves >45 degrees may progress a degree/year • Mortality not increased unless curve >90 degree • Right heart failure • Decreased pulmonary function

  33. Non-Operative Treatment • <25 degrees monitor every 4-12 months • Depends on skeletal maturity • >25 degrees monitor every 3-6 months • >30 degrees in skeletally immature brace • Curve change by 10 degrees brace • Curve >40-45 degrees surgery

  34. Idiopathic scoliosis – conservative treatment

  35. Bracing • Duration and time in brace • 23 hours per day • Wear until skeletally mature • Types • Milwaukee • Underarm orthosis • Charleston night time bending brace • Electrical stimulation

  36. Braces

  37. Successful Bracing • Prevent curve progression • Randomized study • Braced 74% did not progress • Not braced 34% did not progress • Electrical stimulation • 33% did not progress • Charleston brace still controversial

  38. Problems with Braces • Argued efficacy • Narrow treatment window to initiate • Poor compliance • Must have good orthotist • Curves corrected by 20 degrees in brace do better

  39. Treatment Algorithm

  40. Surgery • Failed bracing • Curves >45 degrees • Unbalanced curves >40 degrees • Surgery is fusion with instrumentation

  41. Surgical treatment • Technique of choice is transpedicular instrumentation with hooks and rods combine with posterior fusion according to CD rules

  42. Preoperative planning • Identification of stable vertebras

  43. Surgical technique – patient positioning • Pronate position • General anesthesia • Antybiotic prophylaxis • Blood supply

  44. Surgical technique – approach • Incision in posterior midline

  45. Surgical technique – approach • Periostal incision,

  46. Surgical technique • Transpedicular screw implantation

  47. Surgical technique

  48. Surgery

  49. Surgery

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