Scoliosis
- 2. 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.
- 3. • 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.
- 4. Incidence of Scoliosis • Develops between ages 8 to 15 (growth spurt) • 7 times more prevalent in females • 80% of scoliosis origin unknown
- 5. “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
- 6. Lateral displacement • Angular displacement
- 7. Classification • I. Non structural Scoliosis (Postural) • II. Transient Structural Scoliosis • III. Structural Scoliosis
- 8. I. Non structural Scoliosis • Postural Scoliosis • Compensatory Scoliosis II. Transient Structural Scoliosis • Sciatic Scoliosis • Hysterical Scoliosis • Inflamatory Scoliosis
- 9. 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
- 11. • NEUROMUSCULAR DISORDER ASSOCIATED SCOLIOSIS NEUROPATHIC oPoliomyelitus oCerebral palsy oSyringomyelia MYOPATHIC oMuscular dystrophy oUnilateral Amelia oFriedreich’s ataxia
- 12. • TRAUMATIC SCOLIOSIS o Vertebral o Extra vertebral eg: Burns eg: Fractures, irradiation Surgery
- 13. 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.
- 15. Physiological Effects of Scoliosis • Mid-back pain • lower back pain, • neck pain, headaches, • premature disc and joint degeneration • Decreased pulmonary function
- 16. 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
- 17. • 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
- 18. • 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)
- 19. • 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
- 20. • 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.
- 21. – Function of curves • Strength • Flexibility
- 22. • 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
- 23. Type I - lumbar dominant (10%) - S- shaped curve, Both thoracic and lumbar curves cross midline, Lumbar curve larger or more rigid King classification
- 24. Type II - thoracic dominant (33%) - S-shaped curve, Both thoracic and lumbar curves cross midline, Thoracic curve larger or more rigid King classification
- 25. Type III - thoracic (33%) - Thoracic curve, Lumbar curve does not cross midline King classification
- 26. Type IV - long thoracic (10%) - Long thoracic curve, L5 over sacrum, L4 tilted into curve King classification
- 27. Type V - double thoracic (10%) - Double thoracic curve, T1 tilted into upper curve, Upper curve structural King classification
- 28. 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
- 29. • Self-limiting • Spontaneously resolve (70% to 90%) • Progressive - – Compensatory or secondary curves develop, – > 37 degrees by Cobb Method
- 30. 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
- 31. • 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
- 32. 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.
- 33. • 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 ADOLESCENT IDIOPATHIC SCOLIOSIS
- 34. Problems in adult life (1)Back pain, (2)Pulmonary dysfunction, (3)Psychosocial effects, (4)Mortality
- 35. • Slightly more in females • More common in right • Features midway between adolescent thoracic & lumbar THORACOLUMBAR
- 36. • Common in females • 80% convex to left • One hip prominent • Not noticed early • Backache in adult life LUMBAR SCOLIOSIS
- 37. • 2 primary curves, one in each direction • Radiologically severe • Clinically less noticable • Because always well balanced COMBINED SCOLIOSIS
- 38. 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.
- 39. • 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.
- 40. Types of structural scoliosis • Idiopathic scoliosis (no obvious cause). • Congenital or Osteopathic.(bony abnormality). • Neuropathic • Myopathic (Associated with muscle dystrophies)
- 41. 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
- 43. • 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
- 44. • 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
- 46. • 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
- 47. CLINICAL EVALUATION • Plumb line - On posterior aspect, line drawn from occiput should normally align with gluteal cleft
- 48. 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
- 49. 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.
- 50. • 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
- 51. X Ray Standing AP film of whole spine on one film.
- 52. 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.
- 53. Radiographs are assessed for • Spinal column contour • Congenital or developmental abnormalities, • Degenerative • Neoplastic abnormalities
- 54. CURVE MEASUREMENTS • COBBS METHOD • RIB ANGLE OF MEHTA • SCOLIOTIC INDEX • RISSER-FERGUSON METHOD
- 55. • End-vertebrae - maximum rotated vertebra (most tilted vertebrae ) • Apical vertebra-Vertebra at the centre of the curve.
- 56. • 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
- 57. 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.
- 59. 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
- 60. More than 200 or overlap of the head of the rib over the vertebra are associated with a high likelihood of progression.
- 61. •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
- 62. •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
- 63. 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
- 64. • 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
- 65. • 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
- 66. Moe pedicle method • Divides the vertebra into six equal parts. • Normally, the pedicles appear in the outer parts
- 67. 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.
- 68. • Secondary sex characteristics • Bone age • Excursion of iliac apophysis (Risser's staging) • Ossification of the vertebral ring apophysis. DETERMINING MATURATION
- 69. Ossification of the vertebral ring apophysis
- 70. Excursion of iliac apophysis • Ossification of iliac crest starts laterally & proceeds medially toward sacrum. • Maturation complete, when it reaches Sacroiliac junction
- 71. 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
- 72. CT scans are used to provide improved definition of abnormalities of vertebral size, shape or number
- 73. Magnetic resonance imaging - to evaluate the spinal cord and spinal nerves. Myelography
- 74. Other Studies Pulmonary function testing for patients with: Curves greater than 60 degrees Respiratory complaints Scoliosis resulting from a neuromuscular cause
- 75. TREATMENT
- 76. Aims of treatment 1) To prevent progression of the deformity 2) To correct an existing deformity
- 77. Nonoperative treatment • Observation • Orthotics – braces • Traction and Casting
- 78. Non operative • Exercises maintain muscle tone but no effect on the curve • If curve between 20* & 30* is progressing, bracing done TREATMENT
- 79. Orthotics • Hibbs and Risser – Turnbuckle cast • Milwaukee brace ( CTLSO )– 1946 • Thoracolumbosacral othosis (TLSO’s) – 1960s
- 80. Milwaukee brace • Pelvic girdle • Uprights – one anterior and two posterior. • Cervical ring with throat mold and occipital piece • Lateral pad – pressure on apical vertebra
- 82. 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
- 83. • 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
- 84. 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
- 85. SURGERY Criteria :- 1.Curve more then 40degree 2.Progressive increase in scoliosis 3.Failure to conservative treatment 4.Cardiopulmonary complications.
- 86. 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.
- 87. • 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
- 88. • 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
- 89. • 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)
- 90. • 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
- 91. • 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)
- 92. • 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
- 93. 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
- 94. PARALYTIC SCOLIOSIS • Conservative---- fitting a suitable sitting support. • Surgery---- stabilisation of entire paralysed segment by combined anterior & posterior fusion.
- 95. CEREBRAL PALSY SCOLIOSIS • Most often thoracolumbar curve • Pelvic obliquity & hip contracture present INDICATIONS • Progressive curve of any degree • Normal mortality
- 96. TREATMENT • For severe lumbar & thoracolumbar curves anterior fusion with dwyer instrumentation then after 2 weeks posterior fusion with harrington rods.
- 97. 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.
- 98. 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.