Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital Jaipur
Scoliosis - Basics Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital Jaipur What is scoliosis Demographics & Etiology Clinical Evaluation Radiological Evaluation Treatment Scoliosis Abnormal lateral curvature of spine Deformity in the coronal plane 3 Dimensional Deformity
Coronal Plane Sagittal Plane Axial Plane 3 Dimentional Deformity Demographics Occurs in 1-3% of population below the age of 16 years.
0.1% have a curve greater than 40 degrees. Girls are more affected than boys. Those with a curve of more than 30 degrees are generally girls, outnumbering boys by 10:1. Types of Scoliosis Congenital Neuromuscular Syndromic Idiopathic
Cerebral palsy / PPRP Syndromic Marfans syndrome Neurofibromatosis Idiopathic 80% - Most common Degenerative Idiopathic - Classification
Infantile:0-3 years old (.5%) Juvenile: years old (10.5%) Adolescent: years old (89%) Early Onset : 5 years or less Late Onset:more than 5 years Anatomy All bony elements are altered Discs are wedged as well
Vertebra are wedge shaped Poorly Developed Concave side Pedicles rotated Discs are wedged as well Etiological Theories Genetic Tissue deficiencies Growth abnormalities
Central nervous system alteration Genetic Strongly Familial 11% incidence in first relatives of patients
Normal incidence < 3% Monozygote twins more common Gene identified Chromosome 3p26. LBX1, DSCAM gene Tissue Deficiencies Marfans syndrome deficient fibrillin
Osteopenia noted in girls Elevated calmodulin Involved in contractile properties thru actin & myosin Elevated in platelets No consistent findings to date 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 Central Nervous System
Different size cerebral cortices Associated Syrinx, Low lying cord, Arnold Chiari Malformation Functional Spinal Cord Tethering Deficient melatonin Chicken model Inconclusive in humans History First noted and progression 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 Physical Exam Iliac crest height Shoulder height Arm trunk space
Leg length discrepancy Shoulder height Arm trunk space Scapular position Trunk shift Neuro exam /Muscle charting Generalized Features Marfans Inspection of skin Caf au lait spots Hair patch Physical Examination:
Features suggestive of polio, neurofibromatosis, Von Reclinghausen syndrome, Downs, Marfans, Hurlers syndrome, neural tube defects and osteogenesis imperfecta. Forward protrusion of chest wall on affected side. Increased flank creases on opposite side. Higher ASIS and PSIS on concave side. Spinous process turned into concave side. Forward Bend Test Adams sign Radiological Evaluation
PA & Lateral Whole Spine Standing Films Posterior to anterior Decrease thyroid and breast exposure 3-7 fold AP Whole spine right and left bending films lying down Traction X-rays Fulcrum Bend X-rays Scoliosis Analyzing Curve
Structural and Non Structural Primary Curve and Secondary Curve End vertebra Apex Cobbs Angle Stable zone Rotation Structural Curve Position Independent Fixed deformity
Structural changes Primary Curve Structural Lateral Curvature with Rotation
Recognized Clinically Measured Radiographically End Vertebra Most tilted vertebra Last to show rotation of Spinous process Pedicle width equal on each side Neutral Disc / Neutral Vertebra Compensatory Curves Above and below the primary curve
In opposite direction to primary curve No fixed clinical rotation Righting Reflex Measurement of Scoliosis Cobbs Angle Rotation Spinous process rotates into concavity
Nash & Moe method - Pedicle position Stable Zone / Stable Vertebra Nomenclature Cervical C1 to C6-7 Disc Cervicothoracic C7 to T1
Thoracic T1-2 Disc to T11-12 Disc Thoracolumbar T12 to L1 Lumbar L1-2 Disc to L4-5 Disc Lumbosacral L5 and below T5 T9 Compansatory Curve 760 L1 Skeletal Maturity History and Physical Exam
Triradiate cartilage fusion Risser sign Kings Classification
Double curve, both curve cross the midline, Lumbar curve larger , stifferthan the thoracic curve Double curve, both cross the midline Thoracic curve larger, stifferthan the lumbar curves. Long thoracic curve in which L5 is centered over sacrum but L4 tilts into long thoracic curve Thoracic curve and T1 tilts to upper curve Thoracic curve crosses midline andlumbar curve does not cross midline Lenke Classification MRI Neurologic deficit Infantile and juvenile curves
Spinal cord abnormality in younger children Infantile idiopathic scoliosis 50% Juvenile 20% Who needs an MRI: A thoracic curve to the left. Painful scoliosis.
Abnormal neurological findings. Untoward stiffness. Deviation to one side during the bend test. Sudden rapid progression of a previously stable curve. Treatment Natural History - Curve Progression
Curves 30 to 50 degrees progress an average of 10 to 15 degrees over a lifetime. Curves > 50 at maturity progress steadily at a rate of 1 degree per year. Curves less than 30 at bone maturity are unlikely to progress. Medical complications:
At 90 degrees or greater: increased potential for life threatening effects on pulmonary function. Psychologic illness:seen in up to 19% of females with curves great than 40 degrees as adults. Natural History Close relationship b/w increase in height & curve progression Infantile rapid stage Juvenile slow stage Adolescent rapid stage Mature slow stage Will the curve progress?
Three factors involved in progression Patients gender Females are 10 times more likely to have progression than males. Future growth potential Skeletal Maturity Radiological / clinical Curve magnitude at time of diagnosis The greater the growth potential and larger the curve = more likely to progress Treatment Observation Bracing Surgery Treatment RISSER CURVE Action 0 - 1 0 - 20 degrees 20 - 40 degrees
Observe Brace 2 - 3 degrees 30 40 degrees 0 - 3 0 - 4 40 50 degrees 50 degrees and higher Gray Surgery Bracing Orthotic braces - 74% success rate at halting progression
Must be worn hours a day, but most pts are not compliant. Braces do not correct scoliosis. Braces Bracing - Contraindications
Curves >450 Patient with noticeable Trunk shift Skeletally mature adolescents Riser 4-5, 2 yrs post menarchal Curve apex above T6 Excessive Thoracic Hypokyphosis < 200 Scoliosis - Surgery Fusion gold standard
Creating a well balanced spine both Sagittal and Coronal plane Instrumentation to maintain acceptable alignment Non-fusion options - developmental Surgery Anterior Release Anterior Instrumenation
Posterior Instrumentation Osteotomies - Pontes VCR Growth rods Tests of flexibility of spine:
Adams forward bending test. Pushing the curve from convex side and noting the correction. Lifting the patient up from head. X-rays - Lateral bending / Fulcrum bend /Traction X-Rays Early Onset Scoliosis Preserve as much growth potential as possible
Lung development Thoracic insufficiency syndrome 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 Congenital Scoliosis Vertebral malformation Rib Anomalies
Failure of formation Failure of segmentation Mixed Rib Anomalies Spinal cord anomalies Urogenital / Cardiac Growing Rod Technique Conclusion Scoliosis is common most are lordoscoliosis
Treatment depends on remaining growth potential, curve magniitude, and sex Goal of treatment is to have a curve of < at Skeletal Maturity Bracing Surgery Thank You Dr. Lalit Sharma lalitspine@gmail.com
Consultant Spine Surgeon Narayana Hrudayalaya Hospital Jaipur