Spinal deformities

Yoram Anekstein M.D.

Assaf Harofeh Medical Center
Spine Surgery Unit
Anatomical alignment of
vertebral column
 Spinal deformities
• Scoliosis - coronal.
• Hyperkyphosis/hypokyphosis -
sagital.
 Spinal deformities -
Etiology
• Idiopathic
• Degenerative
• Post-traumatic
• Infectious
• Pathologic
• Congenital
• Metabolic
• Inflammatory
Scoliosis
 Scoliosis

The scoliotic patient

actually has a 3D
deformity.
 Scoliosis
Two groups of patients
Many different types of diseases

Pediatric

Adult
 CLASSIFICATION

Pediatric scoliosis

1. Structural scoliosis
2. Nonstructural scoliosis
 CLASSIFICATION
Nonstructural
1. Postural
2. Nerve root irritation
-Disc hernia
-Infection
-Tumor
3. Leg length discrepancy
4. Lower limb contracture
 CLASSIFICATION
Structural scoliosis
1. Idiopathic
2. Neuromuscular
3. Congenital
4. Neurofibromatosis
5. Traumatic
6. Extraspinal
7. Skeletal displasia
8. Metabolic
9. Mesenchymal
 Idiopathic scoliosis -
defenition

“Structural lateral curvature of the

spine for which no cause can be
established”.
 Idiopathic Scoliosis

1. Infantile (0-3 Years)

2. Juvenile (3-10 Years)
3. Adoloscent (>10 Years)
 Epidemiology in idiopathic
scoliosis
• Mild = 25/1000
• Sever = 1-3/1000
• Female/Male ratio:
– Mild = 1.4
– Sever = 10
 GENETICS
in idiopathic scoliosis

HEREDITARY DISEASE ??
1. Increased incidence in family
members.
2. Multiple gene inheritance
3. Gene & gene products are
unknown.
 CAUSATIVE FACTORS
in idiopathic scoliosis
• Paravertebral musculature, spinal
ligaments and bone pathology.
• Endocrine
• Central Nervous System
• Melatonin (pinealectomy in
chikens).
 NATURAL HISTORY
in idiopathic scoliosis
1. Curve progression.
2. Back pain.
3. Pulmonary function.
4. Mortality.
5. Psychosocial effects and body
image.
 Curve progression
in idiopathic scoliosis

1. Curve specific factors

-Larger curve>Smaller curve
-Female>10 time than male
2. Growth potential
- immature patient > mature
 Curve progression

After maturity if >

50 to 75 deg, than
1 degree/year.
 Pulmonary Function

1. With thoracic curves.

2. Lordoscoliosis.
3. Cobb 100-120 degr.
 History
Differential Progression
Diagnosis
• Signs of puberty
• Family history (menses)
• Pain !! • Age of onset &
• Neurologic rate of
symptoms. progression.
Screening test
Physical examination

Essentials (2).lnk
 Physical examination
• Limb length
• Skin signs
• Pubertal development (Tanner)
 Radiologic assessment
• Standing radiograph of entire spine
in AP & lateral projections.
• Lateral bending radiographs (for
surgical planing).
Types of idiopathic
scoliosis
King classification
Idiopathic = right thoracic.
 Cobb angle

• RT T6-L1 50
Apex T10
• LT L1-L5 30 5
0

30
Lateral bending
radiograph

22

RT T6-L1 50 >
22
 MRI - indications
• Structural abnormalities.
• Left thoracic curve.
• Neurologic signs.
• Rapid progression.
• Early onset.
Structural abnormalities -
example
No radiation - Orthoscan
Idiopathic scoliosis
TREATMENT
 Idiopathic scoliosis
TREATMENT

Only Brace and Surgery are

effective.
 Idiopathic scoliosis
TREATMENT GUIDLINES
• Curve magnitude
– If > 25 deg = Brace
– If > 40-50 deg = surgery
• Curve progression.
• Skeletal maturity.
 Bracing
Boston type (TLSO)
Milwaukee
(CTLSO)
 Bracing
• Cheneau
 TREATMENT -
Conservative
* What is the deformity we are
treating?
* Why are we treating it?
* Do we treat it successfully
conservatively?
 TREATMENT -
Conservative
* PHYSIOTHERAPY?

1. For the sagittal component

2. Maintain muscle tone
3. Post surgery
4. At the end of conservative
treatment
 TREATMENT - Surgical

• Progressive
• large curve >50 deg
• THE GOALS:
– Stop progression
– Get a balanced
spine
– Correct deformity
 TREATMENT - Surgical
approaches
1. Posterior
- Thoracic
2. Anterior
- Lumbar / Thoracolumbar
3. Combined
- Rigid
-Young child
- Severe curve
Distraction/Compression
devices
(Harrington).
Translation producing
devices
(Luque)
Derotation/3 “D”
Correction
b
TREATMENT - King type 2
Posterior approach
Anterior approach
Anterior approach
 COMPLIATIONS
1. Instrumented related
2. Correction related
3. Surgical related
 Scoliosis - Summery
• “Many” different diseases and
etiologies.
• A 3D deformity
• In the pediatric age: Adolescent
Idiopathic Scoliosis is most
common
• Look for structural and neurologic
abnormalities.
 Scoliosis - Summery
• Progression is related to curve
magnitude and to skeletal
maturity.
• Clinical approach:
– Follow up
– Brace
– Surgery
• The goal of treatment - Stop
progression and get a well
THANK YOU
HYPERKYPHOSIS
 HYPERKYPHOSIS
in children and
adolescents
• Postural
• Scheuermann’s
• Congenital
• Skeletal Dysplasia - Achondroplasia
 Postural Round Back
• Flexible thoracic curve of 45-70
degrees.
• Poor posture & extensor musle
tone.
• Poor cosmetic appearance and
increase in back pain.
Postural Round Back
Postural Round Back
 Scheuermanns kyphosis
• Idiopathic
• Genetic transmission
• Onset at around age of 10
(Prepuberty).
•A rigid Hyperkyphosis
 Scheuermanns kyphosis
Types

• Thoracic - apex at T7-T9

• Thoracolumbar - apex at T10-L1
• Lumbar
 Scheuermanns kyphosis
Clinical problems

• Cosmetic deformity
• Pain
• The natural history tend to be
benign.
 Scheuermanns
kyphosis

Radiographic criteria
• Kyphosis > 40 deg
• Vertebral wedging
(> 5 deg in 3 consecutive
vertebrae)
• Irregular end plates & Schmorles
 Scheuermanns
kyphosis
Treatment

• Follow-up and exercises.

• If 50-75 deg in immature patient -
Brace.
• If > 80-90 deg in mature patient -
surgery.
Bracing of hyperkyphosis
Scheuermanns kyphosis
Scheuermanns kyphosis
 Hyperkyphosis
in adults
• Post-traumatic
• Infectious - Potts disease
• Skeletal Dysplasia - Achondroplasia
• Metabolic - Osteoporotic
• Inflammatory - Ankylosing Spondylitis
• Postsurgical - Laminectomy
 Potts disease
Once, a common etiology to
hyperkyphosis
 Osteoporotic Vertebral
Fractures
• 700,000 per year in US.
• Is it a benign problem ?? - NO !!
• Pain > inactivity > more bone loss
> more fractures
• Deformity > reduced lung function
• Possible neurologic deficit
Osteoporotic Vertebral
Fractures
Increased mortality
• 5 y survival worse than age
matched peers
• Hip # - high death rate within 6 mo
but back to baseline at 2 y
• Vertebral # - steady decline in
survival
 Osteoporotic Vertebral
Fractures
Kado, Arch Intern Med 1999
• Prospective, 8 years, 9575
patients.
• VCF increase mortality rate in 23-
34%.
• Most common cause of
death: pulmonary diseases.
 Minimally-invasive
treatment for VCF
Vertebroplasty
• France 1986
• Percutaneus high pressure
injection of cement.
• 70-90% pain relief.
• Well tolerated.
Vertebroplasty
Vertebroplasty
 Minimally-invasive
treatment for VCF
Vertebroplasty - complecations
Up to 65% leak
3% radicular pain
Cement PE - reported
Neurologic def. - rate unknown
 “Maximally”-invasive
treatment for VCF
• Indication: neurologic deficit and/or
sever deformity.
• High rate of mechanical and
medical complications.
 Conclusions

New trends in spine surgery:

• Minimally invasive techniques for
treating osteoporotic spinal
fractures.
• Spinal fusion for this population
carry hign risks.
THANK YOU