Scoliosis

HOD:PROF.DR.K.PRAKASAM

M.S.Ortho,D.Ortho,DSC (HON)MODERATOR:DR.A.E.MANOHARAN

PRESENTOR:DR.THOUSEEF.A.MAJEED

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.

Incidence of Scoliosis

• Develops between ages 8 to 15 (growth spurt)• 7 times more prevalent in females• 80% of scoliosis origin unknown

“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

Classification

• I. Non structural Scoliosis (Postural)

• II. Transient Structural Scoliosis

• III. Structural Scoliosis

I. Non structural Scoliosis

• Postural Scoliosis

• Compensatory Scoliosis

II. Transient Structural Scoliosis

• Sciatic Scoliosis

• Hysterical Scoliosis

• Inflamatory Scoliosis

III. Structural Scoliosis• Idiopathic Scoliosis Old Classification

Infantile Onset < 3 yrs Age

Juvenile Onset 3-10 yrs Age

Adolescent Onset > 10 yrs Age New Classification

– Early onset Onset < 8 yrs Age

– Late onset Onset > 8 yrs Age

• NEUROMUSCULAR DISORDER ASSOCIATED SCOLIOSIS

NEUROPATHICoPoliomyelitus

oCerebral palsy

oSyringomyelia

MYOPATHICoMuscular dystrophy

oUnilateral Amelia

oFriedreich’s ataxia

• TRAUMATIC SCOLIOSIS

o Vertebral

o Extra vertebral eg: Burns

eg: Fractures, irradiation Surgery

OTHER CAUSES OF SCOLIOSIS

• Neurofibramatosis

• Marfan’s syndrome

• Moroquio’s disease

• Arthrogryposis multiplex congenita

• Rheumatoid arthritis

• Stills disease

• Scheuermann’s disease

• Osteogenesis imperfecta

• Scoliosis assosiated with spinal tumours.

Physiological Effects of Scoliosis

• Mid-back pain

• lower back pain,

• neck pain, headaches,

• premature disc and joint degeneration

• Decreased pulmonary function

Descriptive terms• The side towards which the convexity of the curve is directed

is designated as Right or Left.

• The involved location of the curve is described as

1. Cervial

2. Cervico thoracic

3. Thoracic

4. Thoracolumbar &

5. Lumbar

• Simple curve-Single spinal

deviation

• Compound curve-Displacements

in Right & Left direction

• Primary curve- Curve that

develops first

• Secondary or

Compensatory curve-Develops

as a balancing response to the primary

curve

• Non structural curve- Curve

is flexible and corrects by bending

towards convex side

• Structural curve- Curve is not

corrected on bending on convex side

( vertebral and para-vertebral bodies

and soft tissues are deformation

developed)

• Major curve-Significant structural

changes take place (the one of greatest

degrees)

• Minor curve-Secondary or compensatory

curve in the opposite direction above and

below the major curve.

• Usually functional and nonstructural

• Double major curve: Two

balancing curve of equal

structural change and magnitude.

• Thoracic curve is major and the

lumbar curve is structural.

• Because the main thoracic curve

is always larger than the

thoracolumbar/lumbar curve.

– Function of curves

• Strength

• Flexibility

• Most commonly used classification

• Describes 5 specific types of thoracic curves

based upon coronal radiographs

• Recommended specific fusion levels depending

upon the curve type.

KING CLASSIFICATION

Type I - lumbar dominant (10%) - S-

shaped curve, Both thoracic and

lumbar curves cross midline, Lumbar

curve larger or more rigid

King classification

Type II - thoracic dominant

(33%) - S-shaped curve, Both

thoracic and lumbar curves

cross midline, Thoracic curve

larger or more rigid

King classification

Type III - thoracic (33%) -

Thoracic curve, Lumbar curve

does not cross midline

King classification

Type IV - long thoracic

(10%) - Long thoracic

curve, L5 over sacrum,

L4 tilted into curve

King classification

Type V - double thoracic (10%) -

Double thoracic curve, T1 tilted

into upper curve, Upper curve

structural

King classification

INFANTILE IDIOPATHIC SCOLIOSIS

• Younger than age of 3 years

• Boys > girls,

• Primarily thoracic and convex to the

left.

• One hip is prominent but no ribs to

accentuate deformity

• Associated with Mental deficiency,

Congenital dislocation of hip,

Congenital heart defects

• Self-limiting

• Spontaneously resolve (70% to 90%)

• Progressive -

– Compensatory or secondary curves develop,

– > 37 degrees by Cobb Method

JUVENILE IDIOPATHIC SCOLIOSIS

• Uncommon

• Between the ages of 4 and 10 years

• Right Thoracic curves

• 12% - 21% of idiopathic

• Prognosis is worse

• Surgical correction may be necessary before puberty

• Commonest type

• Age 10- 16 yrs

• Primary thoracic curve usually convex to right

• Lumbar curves to the left

• Intermediate (thoracolumbar) & combined (double primary)

curves also occur

• Curves under 20 degree either spontaneously or remain

unchanged

ADOLESCENT IDIOPATHIC SCOLIOSIS


Proposed etiological factors,

(1) genetic factors,

(2) neurological disorders,

(3) hormonal and metabolic dysfunction,

(4) skeletal growth,

(5) biomechanical factors, and

(6) environmental and lifestyle factors.

• Once starts to progress, it goes

on throughout growth period

• Reliable predictors of

progression

1) Very young age

2) Marked curvature

3) Incomplete Risser sign at

presentation


Problems in adult life

(1)Back pain,

(2)Pulmonary dysfunction,

(3)Psychosocial effects,

(4)Mortality

• Slightly more in females

• More common in right

• Features midway between

adolescent thoracic & lumbar

THORACOLUMBAR

• Common in females

• 80% convex to left

• One hip prominent

• Not noticed early

• Backache in adult life

LUMBAR SCOLIOSIS

• 2 primary curves, one in each

direction

• Radiologically severe

• Clinically less noticable

• Because always well balanced

COMBINED SCOLIOSIS

Structural scoliosis

• Non correctable deformity of affected spinal segment.

• Vertebral rotation is an essential component.• Spinous process swing round towards the

concavity of the curve.• Transverse processes on the convexity rotates

posteriorly.

• In thoracic region the rib on the

convex side stand out predominantly

& produces rib hump.

• Initially deformity is corrected.

• When deformity is fully established

the deformity is liable to increase

through out the growth period.

Types of structural scoliosis

• Idiopathic scoliosis (no obvious cause).• Congenital or Osteopathic.(bony abnormality).• Neuropathic• Myopathic (Associated with muscle

dystrophies)

Congenital or Osteopathic- Due to defect in segmentation or

defect in the formation including - Hemivertebra - Block vertebra - Wedged vertebra - Curves progress rapidly during

pre- adolescent growth period

CONGENITAL SCOLIOSIS

• Curve is long, convex towards the side with weaker

muscles ( spinal, abdominal or intercostal) & at first

mobile

• Loss of stability & balance which makes sitting

difficult in severe cases

• Loss of sensibility causes pressure ulceration

B.PARALYTIC SCOLIOSIS

• Deformity is usually the presenting symptom

• Pain is rare complaint

• 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

• Trunk should be exposed completely

& examined in front , back & side

Trunk alignment

• Symmetry of shoulder girdles

• Scapula & ribcage observed for

asymmetry

• Spinous process palpated to determine

their alignment

CLINICAL EVALUATION

CLINICAL EVALUATION• Plumb line - On posterior aspect, line drawn

from occiput should normally align with gluteal cleft

SCOLIOMETRY• The patient bends over, arms

dangling and palms pressed

together, until a curve is

observed in the back.

• The Scoliometer is placed on the

back and measures the apex (the

highest point) of the upper back

curve.

Bunnell Scoliometer

ADAM’S FORWARD BEND TEST

• Patient is asked to lean forward with feet together and bend 90 degrees at

the waist.

• The examiner can easily view the angle & any asymmetry of the trunk or

any abnormal spinal curvatures.

• To determine the severity of the curve

• X-ray Antero Posterior, Lateral & Oblique view of

spine

• Right & left bending view – determine the degree

of flexibility of spine & to see how much curve can

be passively corrected

RADIOLOGY

X Ray Standing AP film of whole spine on one film.

Lateral flexion AP radiographs

• provide information on the upper

and lower limits of a fixed curve

• Mobility of the motion segments, as

an aid to fusion levels.

Radiographs are assessed for • Spinal column contour• Congenital or developmental abnormalities,• Degenerative • Neoplastic abnormalities

CURVE MEASUREMENTS

• COBBS METHOD• RIB ANGLE OF MEHTA• SCOLIOTIC INDEX• RISSER-FERGUSON METHOD

• End-vertebrae -

maximum rotated

vertebra (most tilted

vertebrae )

• Apical vertebra-Vertebra

at the centre of the curve.

• Line drawn at end plate of

upper end vertebra

• Another line at lower border

of lower end vertebra

• Perpenidular lines are drawn

from above two lines

• Angle formed between them

measured

LIPPMAN-COBB METHOD

Double curve

• One vertebra is upper end

vertebra for lower curve and

lower end vertebra for upper

curve (transitional vertebra).

Only one line drawn on this

vertebra.

The difference between the

angle formed by a vertical line

through the centre of the

apical vertebral body on an AP

film and the rib on the convex

side and the same angle on the

concave side.

RIB ANGLE OF MEHTA

More than 200 or overlap of the head of the

rib over the vertebra are associated with a

high likelihood of progression.

•Each vertebra (a–g) is considered an

integral part of the curve.

•A vertical spinal line (xy) is first

drawn whose endpoints are the

centres of the upper and lower end-

vertebrae of the curve.

SCOLIOTIC INDEX

•Lines are then drawn from the centre of

each vertebral body perpendicular to the

vertical spinal line (aa', bb', … gg').

•The values yielded by these lines

represent the linear deviation of each

vertebra

•Sum of vertebral body lines, divided by

the length of the vertical line (xy) gives

the scoliotic index

RISSER-FERGUSON METHOD

•First line originating at the centre of

the upper end-vertebra

•Second line from the center of the

lower end-vertebra.

•Angle formed by the intersection of

two lines at the centre of the apical

vertebra gives the degree of curvature

• Rotation – reflects the degree of structural change

& resistance to correction of the scoliotic curve

• 2 methods are used.

• Moe pedicle method

• Cobb spinous-process method.

DEGREE OF ROTATION

• When the vertebra rotates, one pedicle moves

toward the midline

• It is the relationship to midline that determines the

degree of rotation

• Other pedicle moves towards the lateral border of

vertebral body

Displacement of Pedicles

Moe pedicle method

• Divides the vertebra into six equal parts.• Normally, the pedicles appear in the outer parts

COBB SPINOUS-PROCESS METHOD

• Vertebra is divided into six equal parts.

• Normally, the spinous process appears at the center.

• Its migration to certain points toward the convexity of the curve

marks the degree of rotation.

• Secondary sex characteristics

• Bone age

• Excursion of iliac apophysis (Risser's staging)

• Ossification of the vertebral ring apophysis.

DETERMINING MATURATION

Ossification of the vertebral ring apophysis

Excursion of iliac apophysis

• Ossification of iliac crest starts laterally & proceeds

medially toward sacrum.

• Maturation complete, when it reaches Sacroiliac junction

Risser's staging

Based on iliac crest apophysis

ossification

• Type I – ossification of lateral

25%

• Type II – lateral 50%

• Type III – lateral 75%

• Type IV – lateral 100%

• Type V – fusion of Ilium

CT scans are used to provide

improved definition of

abnormalities of vertebral

size, shape or number

Magnetic resonance

imaging - to evaluate the

spinal cord and spinal

nerves.

Myelography

Other Studies

Pulmonary function testing for patients with: Curves greater than 60 degrees Respiratory complaints Scoliosis resulting from a neuromuscular cause

TREATMENT

Aims of treatment

1) To prevent progression of the deformity

2) To correct an existing deformity

Nonoperative treatment

• Observation

• Orthotics – braces

• Traction and Casting

Non operative

• Exercises maintain muscle tone but no effect

on the curve

• If curve between 20* & 30* is progressing,

bracing done

TREATMENT

Orthotics

• Hibbs and Risser – Turnbuckle cast

• Milwaukee brace ( CTLSO )– 1946

• Thoracolumbosacral othosis (TLSO’s) – 1960s

Milwaukee brace

• Pelvic girdle

• Uprights – one anterior

and two posterior.

• Cervical ring with throat

mold and occipital piece

• Lateral pad – pressure on

apical vertebra

Thoracolumbosacral othosis (TLSO’s)

Contra indictions for orthosis

• Curve > 40 °

• Extreme thoracic kyphosis

• Mature adolescent ; Risser grade 4 or 5, girls 2

yrs post menarchal

• High thoracic or cervicothoracic curves

• Daily application of longitudinal & lateral traction

forces mobilize the spine gradually

• Patient in lying position, head end attached with 10

pounds weight pulls proximally

• Pelvic girdle & traction straps with 20 to 30 pounds

weight pull distally

Stretching

Halo traction device

• Spinal skeletal traction &

fixation device

• Halo traction device attached

to skull & is connected to a

plaster body cast by a steel

frame

SURGERY

Criteria :-

1.Curve more then 40degree

2.Progressive increase in scoliosis

3.Failure to conservative treatment

4.Cardiopulmonary complications.

Methods :

1.Herrignton rod :- only fusion of spine

vertrebra , no correction of the deformity.

2.Double rod method : - on every single level

of vertebra of spine is fixed with screws.

3.Vertebral fusion :- fusion of vertebra where

scoliosis develop.

• A rod is applied posteriorly along

the concave side of the curve

• Movable hooks attached to rod

which are engaged in upper &

lowermost vertebra to distract the

curve

Harrington system

• If curve is flexible, it will passively correct &

bone grafts are applied to obtain fusion

Disadvantage

• Does not correct the rotational deformity at the

apex of the curve

• Rib prominence remains unchanged

• Modification of Harrington system

• Wires are passed under vertebral lamina at multiple

levels & fixed to rod on the concave side of the

curve

• Bending the rod & arranging the mechanism so that

wires pull backwards than side wards

• Rotational deformity is improved

ROD & SUBLAMINAR WIRING (LUQUE)

• Posterior rod system with multiple hooks placed at

various levels to produce either distraction or

compression

• With double rods, one can distract on concave &

compress on convex side

• Rotational deformity corrected.

COTREL-DUBOUSSET SYSTEM

• Rigid curves & thora-columbar curves associated

with lumbar lordosis corrected from front.

• Removing the discs throughout the curve & then

applying a compression device in the convex of the

curve

• Bone grafts are added to achieve fusion

ANTERIOR INSTRUMENTATION (DWYER, ZIELKE)

• Treated by applying serial elongation- derotation –

flexion(EDF) plaster casts

• Can be applied till 4yrs

• If deformity deteriorates, surgical correction done

• Anterior disc excision with use of rod to aid

correction

INFANTILE IDIOPATHIC SCOLIOSIS

Non operative treatment

• Milwaukee brace from age 1 or 2yrs until 9 or 10yrs when

surgery is done

• Previously, Risser localizer cast was used in children from 1

to 4yrs

Indications

• progressive curve, moderately flexible

• Non progressive, somewhat flexible but unacceptable

CONGENITAL OR OSTEOPATHIC

PARALYTIC SCOLIOSIS

• Conservative---- fitting a suitable sitting

support.

• Surgery---- stabilisation of entire paralysed

segment by combined anterior & posterior

fusion.

CEREBRAL PALSY SCOLIOSIS

• Most often thoracolumbar curve

• Pelvic obliquity & hip contracture present

INDICATIONS

• Progressive curve of any degree

• Normal mortality

TREATMENT

• For severe lumbar & thoracolumbar curves anterior

fusion with dwyer instrumentation then after 2

weeks posterior fusion with harrington rods.

NEUROFIBROMATOSIS SCOLIOSIS• Constitutes about 1%

• Associated with skin lesions , multiple neurofibroma &

bony dystrophy affecting vertebra & ribs

• Curve is short & sharp

• Mild cases – conservative

• Severe cases – combined anterior & posterior fusion.

SUMMARY

• Curves <20’ needs observation.

• Curves more than 20 treatment.

• Curves between 20 to 40 degree can be treated by

bracing

• Curves > 40 degree needs surgical correction &

fusion.

THANK YOU

Health & Medicine

Scoliosis