Idiopathic Scoliosis: A concise approach to scoliogeny. Dr. Theodoros B Grivas MD, PhD
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1 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece 11 th International Conference on Conservative Management of Spinal Deformities 4 th SOSORT Educational Course, 6-7 May 2014, Wiesbaden (Germany) Idiopathic Scoliosis: A concise approach to scoliogeny Dr. Theodoros B Grivas MD, PhD Traumatology & Orthopaedic Department, "Tzaneio" General Hospital of Piraeus NHS, Tzanni & Afendouli str, 18536, Piraeus, Greece, tgri69@otenet.gr 1
2 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece Definitions For idiopathic scoliosis (IS) aetiology means the factor(s) causing the IS pathogenesis the mode of origin of the morbid process, & pathomechanism the sequence of events in the evolution of its structural & functional changes that result from the pathological process aetiopathogenesis embrace aetiology & pathogenesis 2
3 Definitions Prof RG Burwell (2013) suggested the word scoliogeny as the collective noun to include aetiology, pathogenesis & pathomechanism 3 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
4 Scoliogeny theories, hypotheses & concepts Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece There is a view there are two scoliogenic processes for IS namely initiating (or inducing) & those that cause curve progression IS seems to be a multifactorial condition Burwell et al
5 Scoliogeny theories, hypotheses & concepts 5 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
6 Scoliogeny theories, hypotheses & concepts Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces & axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc (IVD) disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 6
7 Scoliogeny theories, hypotheses & concepts Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signaling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuro osseous theory 7
8 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 8
9 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 9
10 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 10
11 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 11
12 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 12
13 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 13
14 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 14
15 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal w/ normal shear forces tissues and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc (IVD) disorder Deforming background three of joint enhanced complex anabolic hypothesis gene Motor expression control disorder Sensorimotor integration disorder & dystonia Sensory IVD integration disorder Vestibular disorder Elevated synthetic activity in the convex side of scoliotic IVD & endplates compared The elastic fiber network of the annulus fibrosus of the normal & scoliotic human IVD Accelerated IVD degeneration in scoliosis versus physiological ageing develops against a Cobb angle progression in AIS begins at the 15
16 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional buckling from flexibility anisotropy Biomechanical spinal growth modulation Biomechanical theory Intervertebral disc disorder Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder Vestibular disorder 16
17 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal shear forces and axial rotation instability Flexural torsional areas during buckling movement from flexibility anisotropy Biomechanical execution spinal patients growth modulation with IS. Biomechanical The hypothesis theory is that a Intervertebral disc disorder Deforming sensorimotor three joint complex integration hypothesis Motor control disorder Sensorimotor disorder integration underlies disorder the & dystonia Sensory integration disorder pathogenesis of IS Vestibular disorder an abnormal pattern of brain activation in secondary motor 17
18 Relative anterior spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal IS. concept Dorsal shear forces and axial rotation instability Asymmetrical cortical Flexural torsional buckling from flexibility anisotropy hyperexcitability may play an Biomechanical spinal growth modulation Biomechanical theory Intervertebral of IS & represents disc disorderan objective Deforming three joint complex hypothesis neurophysiological finding that Motor control disorder Sensorimotor could be used integration clinically disorder & dystonia Sensory integration disorder Vestibular disorder A dystonic dysfunction underlies in important role in the pathogenesis 18
19 Relative The anterior severity spinal overgrowth of (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal scoliosis shear forces and in axial scoliotic rotation instability Flexural torsional buckling from flexibility anisotropy girls could be related Biomechanical spinal growth modulation Biomechanical to an increase theory in the Intervertebral disc disorder Deforming three joint complex hypothesis sensory integration Motor control disorder Sensorimotor integration disorder & dystonia Sensory disorder integration disorder Vestibular disorder 19
20 Relative The are anterior detected spinal overgrowth (RASO) Asynchronous spinal neuro osseous growth Thoracospinal concept Dorsal are likely shear forces to be and associated axial rotation instability with Flexural torsional buckling from flexibility anisotropy Biomechanical proprioceptive spinal growth dysfunctions modulation Biomechanical theory Intervertebral reported frequently disc disorder in AIS, as it Deforming three joint complex hypothesis Motor control disorder Sensorimotor integration disorder & dystonia Sensory integration disorder vestibular system Vestibular disorder morphoanatomical changes which subclinical postural, vestibular and was demonstrated in MRI based morphoanatomy clinical studies of 20
21 Body spatial orientation disorder Neurodevelopmental disorder two stage hypothesis: Systemic and metabolic disorders involving the natural history of AIS involves an a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia initial stage in which a small curve develops due to a small defect in the neuromuscular control system and a second stage during adolescent Developmental instability & symmetry control growth in which the scoliotic curve is dysfunction Intrinsic exacerbated growth by plate biomechanical asymmetry hypothesis Multiple factors pathogenetic processes: Double neuroosseous theory 21
22 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving curve initiation process rapid spinal elongation in a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin adolescent growth spurt maturational delay of CNS body g. Osteopenia schema Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory movements of spine and trunk, upright posture 22
23 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory 23
24 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory 24
25 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory 25
26 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory 26
27 Body spatial orientation disorder Neurodevelopmental disorder Systemic and metabolic disorders involving a. Platelet calmodulin b. Melatonin c. Melatonin signalling defect (MSD) d. Osteopontin (OPN) and soluble CD44 (scd44) e. Oestrogens f. Leptin g. Osteopenia Developmental instability & symmetry control dysfunction Intrinsic growth plate asymmetry hypothesis Multiple pathogenetic processes: Double neuroosseous theory 27
28 28
29 Normal puberty AIS Initiation Factors Predisposition genes/ initiation genes Environmental factors epigenetics Onset of AIS epigenetics Disease modifier genes/ progression genes epigenetics AIS Progressive factors Curve Progression & Severity 29
30 AIS & Epigenetics epigenetic differences may underlie scoliotic MZ twin discordance, & represent the link between environmental factors & phenotypic differences. 30 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
31 AIS & Epigenetics Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece The word epigenotype was introduced by Waddington (1942) to describe the whole complex of developmental processes between genotype & phenotype, & epigenetics the name for such studies 31
32 AIS & Epigenetics 32 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
33 AIS & Epigenetics Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece Environmental risk factors for AIS Monozygotic twins & spinal radiology in AIS ( Wynne-Davies 1968, Smyrnis et al 1987, Kesling & Reinker 1997, Inoue et al 1998, van Rhijn et al 2001, Fraga et al 2005, Martin 2005, Andersen et al 2007, Hermus et al 2007, Miller 2007, Kaspiris et al 2008, Sales et al 2010, Wong et al 2010, Grauers et al 2010, Day and Sweatt 2011) A food & growth connection (Golding 1991, Worthington & Shambaugh 1993, Enwonwu & Sanders 2001, Kaati et al 2002, Veyver 2002, Burwell 2003, Burwell and Dangerfield 2004 Bjornsson et al 2004a, Feinberg 2007, Feinberg 2008, Greene et al 2011, Ford et al 2011, Francis 2011) Relative osteopenia & life-style factors (Hung et al 2005, Lam et al 2011, Wang et al 2011) Physical activities of patients with AIS (Bagnall 2000, McMaster et al 2004, 2006) Geographic latitude & the prevalence of AIS (Grivas et al 2006) Maternal age & socio-economicstatus (De George and Fisher 1967, James & Wynne-Davies 1969, Ryan & Nachamson 1987, Heijmans et al 2009, (Grivas et al 2012) Heated indoor swimming pools infants and delayed epigenetic effects (McMaster et al 2004, 2006, McMaster 2011) Hypothesis of developmental instability for scoliosis (Goldberg 2000, Bjornsson et al 2004, Gluckman & Hanson 2006, Feinberg 2008, Gluckman et al 2011) 33
34 Scoliogenesis of AIS 34 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
35 AIS & Epigenetics 35 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
36 AIS & Epigenetics 36 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
37 AIS & Epigenetics 37 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
38 AIS & Epigenetics 38 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
39 AIS & Epigenetics 39 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece
40 Traumatology & Orthopaedic Department Tzaneio General Hospital of Piraeus, Greece 40
41 Traumatology and Orthopaedics Department Tzaneio General Hospital of Piraeus, 2014 Ακτή Μουτσοπούλου Thank you Ευχαριστώ! T z a n e i o H o s p i t a l
Dr. Theodoros B Grivas MD, PhD
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