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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
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.
• 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.
“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
Lateral displacement • Angular displacement
• Paralytic scoliosis is defined as the increased
lateral curvature of the spine due to paralysis of
spinal muscles.
PARALYTIC SCOLIOSIS
• 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
Classification
• NEUROPATHIC • MYOPATHICNeuropathic• Poliomyelitis Lower motor neuron• Traumatic• Spinal muscle atrophy• Dysautonomia
• Cerebral palsy
• Friedreich ataxia
• Charcot Marie Tooth
• Syringomyelia
• Spinal cord tumour
• Spinal cord trauma
Upper motor neuron
MYOPATHIC
• Arthrogryposis
• Muscular dystrophys
• Congenital hypotonia
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.
• 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 .
• 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)
• 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
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
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
• 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
• 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
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
Proximal to the iliac crest
• Correct obliquity and scoliosis together.
• Fusion to maintain correction .
• Fusion must extend to the sacrum
Above and below the crest
• Both deforming elements must be
corrected(obliquity and scoliosis)
• Fusion must include sacrum
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
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)
• 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.
• 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.
3 Major types of poliomyelitic scoliosis
• High Cervicodorsal kyphoscoliosis
• Long Dorsolumbar scoilosis
• Lumbar Scoliosis
Treatment for poliomyelitic scoliosis
• Conservative treatment
• Surgical treatment
Conservative treatment
• Prolonged recumbancy 6 months in paralysis
of trunk and abdominal muscles.
• Lying on a concave frame favours weak
abdominalis muscle
• Spine should be evaluated every 3months by
standing radiographs.
• Postpoliomyelitic scolotic brace
• 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
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
•
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.
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
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
• Long fusion is necessary to result in a
balanced spine.
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
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.
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
Classification
• Lonstein and Akbarnia classified cerebral palsy into two groups.
• Group I curves
• Group II curves
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.
Group II
• Thoracolumbar curves that extend to the
sacrum with marked pelvic obliquity
• Patients with this curve are non ambulatory
with spastic quadriplegia
• 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
• 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
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.
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
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.
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
Surgeries for arthrogrypostic scoliosis
• Harrington instrumentation and posterior fusion.
• Combined anterior and posterior spinal arthrodesis.
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
Secondary symptoms include • Pes cavus• Scoliosis• Cardiomyopathy• The most common pattern is double structural
thoracic and lumbar curves.• Pelvic obliquity may present.
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.
• 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.
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
• 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
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
Causes for postural scoliosis
• Short leg
• Pelvic tilt
• Local muscle spasm with a prolapsed lumbar disc
• Sciatica-Sciatic Scoliosis.
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.
• Surgery involves the stabilization of the entire paralysed
segment by combined anterior and posterior
instrumentation and fusion.