SCOLIOSIS

Dr. Sandeep Gurung

Apparent lateral curvature of the spine Actually a triplanar deformity with lateral, AP and rotational component

Classification A Postural B Structural Idiopathic Infantile(birth to 3 years) Juvenile(4 to 9 years) Adolescent(10 to 20 years)

 Classification cont. Congenital or osteopathic(bony anomalies) Neuromuscular Upper motor neuron cerebral palsy spinocerebellar degeneration Friedreich ataxia Charcot -marie -tooth diesease Roussy- levy Syringomyelia Spinal cord tumour/trauma

Classification cont. Lower motor neuron poliomyelitis other viral myelitis Spinal muscular atrophy Werdnig-Hoffmann Kugelberg-Welander Dysautonomia(Riley-Day syndrome) Myopathic Arthrogryposis Muscular dystrophy Congenital hypotonia/myotonic dystrophica Miscellaneous Connective tissue disorders/Neurofibromatosis

POSTURAL SCOLIOSIS
Deformity is secondary or compenstory to some condition outside the spine. Short leg, pelvic tilt or PIVD Disppears on flexion/sitting.

STRUCTURAL SCOLIOSIS
Non correctable deformity of the affected spinal segment The initial deformity is probably correctable, but once it exceed a certain point of mechanical stablity the spine buckles and rotates into a fixed deformity which does not disappear with change in posture.

CLINICAL FEATURES
Deformity is usually the presenting sympotm Backache Family history

Infantile idiopathic scoliosis

Before 3 years of age, more frequent in boys primarily thoracic and convex to the left Etiology-multiple including genetic Positional factor-natural tendency of infant to turn right side during first fews months of life-gravity causes plastic deformity of thorax

 In prone position,child can not roll onto its side, prevents asymmetrical moulding of vertebra

 Progressive(increasing rapidly) or resolving spontaneously(in 70 to90%) Resolving type-before 1 years of age,smaller curve at presentation,no compensatory curves,curve with intrauterine positioning Progressive type-Development of secondary curves or curve more than37 degree at presentation. Rib vertebral angle(RVA)

Juvenile idiopathic scoliosis Between age of 4 to 10 years, more progressive than adolescent Specific factor for further evaluation are;a.pain b.rapid progression c.left thoracic deformity e.neurological abnormalities f.loss of bowel and bladder control.

Adolescent idiopathic scoliosis

Commonest Girls(90%) 90% convex to right

Factors related to progression cont.. Girls>boys Define progression as increase 5 degree or more of cobbs angle over two or more visits. Premenarchal/adolescent growth spurt Reisser sign of 0(68% of Reisser sign 0 show progression while 18% those of 3 or 4) Double curve > single curve Thoracic curve> lumber curve More severe curves(Risk of progression for 20 degree curve is 20% that for 50 degree is 90%)

Major considerations in natural history of untreated adolescent idiopathic scoliosis Back pain( 77% in scoliosis as compared with 37% in control groups) location of pain variable, generally unrelated to the location or magnitude of the curve Pulmonary function- affected in thoracic curve,restrictive type of lung disese Psychosocial effects-many adult patients seeking treatment are concerned with cosmetic aspect of this disorder(Deformity)

 Mortality-around 15%,related to thoracic curve > 100 degree, cor pulmonale Curve progression After skeletal maturity, cobb angle > 30 degree and apical vertebral rotation > 30 degree. Patient evaluation Through history,complete physical and neurological examination,height of patient both standing as well as sitting( change caused either by abnormality of lower extremities or spine itself) Neurological examination especially to rule out intraspinal tumours

Assessment of skeletal maturity

Roentgenographic parameter of hand and wrist,development of iliac apophysis(Reisser sign) Maturation of vertebral ring apophysis Secondary sexual charecteristics,development of breast and pubic hairs. Triradiate apophysis in younger children

 Measurement of curve; cobb method

Curve patterns: ponseti and friedman classification Single major lumba curve Single major thoracolumber curve Combined thoracic and lumber curve Single major thoracic curve Single major high thoracic curve Double major thoracic curve

King classification

King classification cont..

Crankshaft phenomenon

Salient features of idiopathic scoliosis

Infantile Age at presentation;Birth to 3 yr Male:Female 1:1 to 2:1 Juvenile Adolescent 4 to 9 yr 10 to 20 yr <6 yr 1:3 1:6 >6 yr 1:6 Incidence; 2 to 3% 12 to 13% 85% Curve type; Left thoracic Right Thoracic Right Thoracic L:R(2:1) R:L(6:1) R:L(6:1) Associated findings;mental deficiency None None CDH,congenital Heart disease Risk of cardiopulmonary Compromise; High Intermediate Low Risk of curve progression; <6 mo:low 67% 23% >1 yr:high Rate of progression;2 to 3 deg/yr 6 deg/yr 1to2deg/mo(pubert

Infantile Juvenile Adolescent Curve ;<1yr:90% 20% Rare Resolution; >1yr:20% Curve 60 to 90 deg 50 to 90deg >90 deg rare Magnitude; Orthotic effective at delaying Decreases the rate Effectively contrManagement; and slowing rate of progression until olscurves<40deg
progression puberty Ultimate proression100% Failure rate 30 to80% Success rate 75to80%

Risk of Crankshaft; High

High

Low

Adult Idiopathic Scoliosis

Diagnosed in a patient older than 20yr of age These curves present since adolescence but,for any reasons diagnosis was delayed. Degenerative scoliosis has more neurogenic complaints while idiopathic has more mechanical complaints. In contrast to adolescent scoliosis,more structural and rigid primary and compensatory secondary curves,diminished elasticity of ligamentous structures and narrowing of disc spaces which combine to stiffen the curve. Because of long lever arm produced, poor fixation obtained in the sacrum.

Congenital scoliosis
Lateral curvature of the spine caused by the presence of vertebral anomalies that result in imbalance of longitudinal growth of the spine. Develop during first 6 week of intrauterine life Often rigid and difficult to correct, early detection and treatment is important Cause; believed to be nongenetic fetal environmental factors

Classification Failure of formation Partial failure of formation(wedge vertebra) Complete failure of formation(hemivertebra) Failure of segmentation Unilateral (unilateral segmented bar) Bilateral(Block vertebra)

Patient evaluation Routine spinal evaluation as well more specific physical findings s/b sought Skin of back;hair patches.lipomata, dimples and scars-underlying anomalous vertebra Neurological evaluation;club foot, calf atrophy,absent reflexes,atrophy of lower extremity Systemic involvement;genitourinary diseses 18%,congenital heart disese7%,diastematomyelia5%

Radiographic evaluation
Any evidence of widening of pedicles or midline bony defects Angle of curve measure by cobb method Tomogram further delineate the type of curve Myelography and MRI if diastematomyelia or neurological abnormality suspected MRI during infancy delineate the anatomical abnormality,may not visible on plain Xray Diagnostic ultrasound evaluation as well as excretory urography

Neuromuscular scoliosis
Contributing factors-loss of muscle strength or voluntary muscle control or loss of sensory abilities(proprioception) Younger age,larger percentage are progressive,continue to progress beyond skeletal maturity,curves long that include sacrum,pelvic obliquity is common,less tolerant of orthotic management Many cases require operative management that require longer fusion or fusion to pelvis

Thank you