Scoliosis

1. Scoliosis www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Patient Particulars • Name : Preeti • Age : 11 yrs • Sex : Female • Student : Class six • Address : Uttar Pradesh • Date of examination : 22/08/07 • Proposed date of surgery : 23/08/07

3. Chief Complaints • Deformity of back & chest x 7 yrs Back pain, Leg length discrepancy, An abnormal gait, Uneven hips Clothes no longer fit correctly (for example, the legs of pants may seem uneven). One shoulder higher than the other

4. History of Present Illness • Patient was alright till the age of 7 yrs • Deformity of back with left-ward tilt along with deformity of chest became apparent • Insidious in onset • Gradually progressive

5. HOPI- (consequences-CNS, RS, CVS) • No H/O localized or radiating back pain • No H/O weakness in either LL, bowel, bladder incontinence • No H/O frequent chest infection • No H/O Breathlessness during exertion or at rest • No H/O chest pain, pedal swelling • No H/O palpitation, syncopal attack

6. HOPI- (etiology) • No H/O trauma to the backbone (traumatic) • No H/O pain, fever or swelling of the back (TB) • The deformity does not get corrected in supine position (postural ) • No H/O leg length discrepancy, neck deformity (compensatory) • No H/S/O neuro-muscular weakness or muscle rigidity (neuromuscular) • No H/S/O seizure disorder • No c/o other body part deformity

7. Associated conditions • Cerebral palsy • Spinal muscular dystrophy • Familial dysautonomia • Friedreich’s ataxia • Skeletal dysplasia • Marfan’s syndrome • Neurofibromatosis • Connective tissue disorders • craniospinal axis disorders (e.g., syringomyelia)

8. HOPI • Exercise tolerance good Birth History • F.T.N.V.D. • Cried immediately after birth • Normal developmental mile stones • Immunized appropriately for the age

9. History of Past Illness • No other major medical or surgical illness Family History • Nothing significant

10. Personal History • Vegetarian • Appetite, sleep, Bowel, bladder, –normal Treatment History • None- No h/o Rx in the form of braces or exercises

11. Anesthetic History • No past h/o anesthetic exposure Allergic History • none

12. General Examination • Alert, conscious, cooperative, playful child • Thin built • Pallor - • Cyanosis - • Clubbing – • Icterus – • Edema – • Neck vein- not engorged

13. Vitals • PR-80/min, regular, normal volume,equally well felt all peripheral pulses, no radio-radial or radio-femoral delay, no special character • B.P.- 110/70mmHg, in right upper limb in supine position • RR- 16/min, regular, thoraco- abdominal • Temperature - afebrile

14. Examination of the Deformity • Lateral curvature of spine • Limited to the thoracic region • Convexity right ward • Spinous processes and interspinous spaces are felt without any gibbus • No tenderness • Rib cage is prominent anteriorly in left side with crowding • Rib cage is prominent posteriorly in the right side

15. Uneven shoulder heights • Prominence of shoulder blade • Increased space between the body and the elbow while standing in natural posture • Uneven hips or waist • One breast appears larger than the other • Chest or rib prominence • One leg appears longer than the other • Appearance of leaning to one side

16. Systemic Exminations Respiratory system: Inspection • Bony deformity of thorax • Trachea- mid line • Unequal bilateral chest expansion(Rt>Lt) • RR-i6/min, thoraco-abdominal

17. Respiratory System Palpation • Chest expansion-2 cm(unequal: rt>lt) • Trachea- mid line • No tenderness • Vocal fremitus- normal in all regions Percussion • Normally resonant over all regions Auscultation • Normal vesicular breath sound • No adventitious sound

18. Cardiovascular System Inspection • Bony deformity over the precordium Palpation • Apex beat-left mid-clavicular line at 5th ICS • No thrill, parasternal heave or lift, no plpable heart sound Auscultation • Heart rate-80/min, regular • Normally heard S1 & S2 • No murmur • No other adventitious sound

19. CNS • Clinically normal Abdmen • Clinically normal

20. Airway • No obvious facial abnormality • Mouth opening- 4 cm • Modified Mallampati Class-1 • Neck movement- adequate • TMD-6 cm • Teeth- intact I.V. Access • Good

21. BHT 35 sec Ability to Cough Positive

22. Clinical Diagnosis • 11 yr old female child with idiopathic juvenile dorsal scoliosis without clinically apparent cardio-respiratory or neuromuscular complication posted for one stage anterior instrumentation and posterior spinal fusion surgery.

23. Investigations • Hb-13.8 gm/dl • Hct- 41.1% • TLC-5600 • Platelet count- 2.18 lacs/cmm • CXR- Rt sided dorsal scoliosis, crowding of rib in left side, decreased left lung volume • ECG- normal • PFT -

24. Definition • Lateral curvature of the spine combined with a rotational component, due to various etiologies, according to the Scoliosis Research Society (SRS).

25. Anatomy

26. Prevalance • Curves >10° -2-3% of the population • Curves >20° affect about 1 in 2500 people. • Curves convex to the right are more common • 'C' curves are slightly more common than double or 'S' curve patterns. • Males are more likely to have infantile or juvenile scoliosis • Female predominance of adolescent scoliosis. • Girls are 7 times more likely than boys to develop a significant progressive curvature • Adolescent Idiopathic Scoliosis, there is a clear mendelian inheritance but with incomplete penetrance

27. C and S curve

28. Causes • Congenital • result of an abnormality of the development of the vertebrae-hemivertebra, rib anomalies, spinal dysrapism • Ass with other congenital anomalies – CHD • Neuromuscular • Poliomylitis, Syringomylia, Muscle dystrophies, cerebral palsy, spina bifida, spinal cord injuries • Poor posture • Unequal leg length • Idiopathic scoliosis • cause unknown • most common form (80%)

29. Associated conditions • Cerebral palsy • Spinal muscular dystrophy • Familial dysautonomia • Friedreich’s ataxia • Skeletal dysplasia • Marfan’s syndrome • Neurofibromatosis • Connective tissue disorders • craniospinal axis disorders (e.g., syringomyelia)

30. Infantile idiopathic scoliosis is a/c ↑ incidence of mental retardation inguinal hernia cong dislocation of hip cong heart disease • Adolescent idiopathic scoliosis most common form most common in girls

31. Prevention Tips - Scoliosis • The most important is early examination and getting doctor’s advice • Unlike poor posture, scoliotic spinal curves can't be corrected simply by learning to stand up straight • Carry weight balanced between two hands • Don’t watch TV always sitting/lying in the same position • Exercise and do sports / physical activities

32. Prevention Tips • Backache is a condition that is often caused by weak muscles • These exercises will help strengthen the muscles which support back and improve posture

33. Symptoms • Back pain, • Leg length discrepancy, • An abnormal gait, • Uneven hips • Clothes no longer fit correctly (for example, the legs of pants may seem uneven). • One shoulder higher than the other

34. Signs of Scoliosis • Uneven shoulder heights • Prominence of shoulder blade • Increased space between the body and the elbow while standing in natural posture • Uneven hips or waist • One breast appears larger than the other • Chest or rib prominence • One leg appears longer than the other • Appearance of leaning to one side

35. Signs of scoliosis

36. Physical Findings • Uneven shoulders • Prominent shoulder blade • Uneven waist • Elevated hips • Leaning to one side

37. Physical examination • Café au lait spots • The feet for cavovarus deformity • Abdominal reflexes • Muscle tone for spasticity • Gait • Signs of other abnormalities (e.g., dysraphism evidenced by a dimple, hairy patch, lipoma, or hemangioma). • A thorough neurological examination is also performed..

38. Telescreening study Measures A. With student standing (grid), observe for: a) high shoulder, b) curved spine, c) uneven shoulder blades, d) uneven hips or waist creases, and e) unequal distance from arm to side of body B. Adams forward bend test Scoliometer measurement (thoracic, thoracolumbar, lumbar) -Angle of trunk rotation (ATR) > 7 degree – referral)

39. Classification • Infantile children ages 3 and under • Juvenile 3-9 years old • Adolescent 10-18 years old • Adult after skeletal maturity • Most common is Adolescent Idiopathic Scoliosis

40. Curves Non-structural = Lateral curvature • vertebral column bends from side-to-side • S-shaped curvature of the spine Structural = Rotation curvature • usually subtle, but is always present in a true scoliosis deformity • twisting deformity of the vertebral bodies

41. Types of curves

42. Diagnosis • Leg length Both legs are measured to determine if they are of equal length • Plumb line A plumb line is "dropped" from the C7 vertebra (in the neck) and is allowed to hang below the buttocks. In scoliosis the line does not hang between the buttocks. • Neurological assessment

43. Cobb’s angle

45. Cobb’s angle and symptoms • <10 normal curvature • >25 ECHO evidence of increased pulmonary artery pressure • >40 surgical intervention • >65 restrictive lung disease • >100 dyspnoea on exertion • >120 alveolar hypoventilation

46. Adams Forward Bend Test • Student should stand erect with feet together • knees fully extended • The palms of both hands touching each other • The student bends forward until the back is horizontal • Asymmetry of the thoracic or lumbar spine may be detected by using a scoliometer • To measure the angle of trunk rotation (ATR) at the thoracic, thoracolumbar, and lumbar areas of the spine

47. Adams test

48. Adams test…

49. Diagnosis… • Scoliometer (inclinometer) is used to measure a rib hump while the patient is bent at the waist. • X-rays (radiographs)-an upright lateral view and side bending. • Risser Sign - x-ray for knowing skeletal maturation. • Lenke Classification • King classification

50. Scoliometer