Freih Odeh Abu Hassan

Transcription

1 Scoliosis Freih Odeh Abu Hassan FRCS(Eng) F.R.C.S.(Eng.), FRCS(Tr&Orth F.R.C.S.(Tr.& Orth.). Professor of Orthopedics University of Jordan Hospital - Amman 1

2 1-Idiopathic Infantile (0-3 years) Juvenile (4-9 years) Adolescent (10+ years) Adult 2- Congenital Failure of formation Failure of segmentation Mixed d 2

3 3-Neuromuscular Myopathic AMC M dystrophy Neuropathic UMNL LMNL Dysautonomia (Riley-Day y Synd.) 3

4 4-Others Neurofibromatosis N t i Mesenchymal (Marfan s, Ehlers-Danlos) Traumatic T Tumors Skeletal dysplasia 4

5 Idiopathic Scoliosis = 80% of scoliosis = Familial = 3 per 1000 of the population has >20 degree curve. = One in 20 children have some degree of deformity of their spine 5

6 Types of Idiopathic Scoliosis 1- Infantile = 0-3 years age (early onset) = 60% Male, 90% left sided thoracic curves common = Plagiocephaly 6

7 = risk for cardio-pulmonary compromise 10-20% = 80-90% resolve, non-progressive. = If rib-vertebra angle > 25 degree (Mehta) Progressive Milwakee brace 7

8 2- Juvenile years age - Progressive -!! need fusion before maturity. -26% cord pathology 8

9 3- Adolescent * Commonest * 10y - maturity (late onset) * F>M 6:1 * Right thoracic 90% * 50% require surgery 9

10 Progression related to = Female sex = Younger age at diagnosis = Significant ifi rotation ti = Single thoracic curve = Large curve > 25 degree = Risser 0-1 = Family history = Growth spurt 10

11 Other Adolescent Types A- Thoracolumbar curves # > in females, > to the right B- Lumbar Curves # > in females # 80% to the left #noribhump presented late C- Double major curves # bad x-ray but well balanced curves 11

12 4- Adult Scoliosis Prevalence: 6-35% persons >50 years old 2.5% patients >20 years old 12

13 Total # patients = 64 Sex: 17 male 47 female Age mean 62yrs (range 25-87y) Symptoms 73 % Back pain 69 % Leg pain 32 % 13

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15 1- Forward bending test 2- Scoliometer 1/16/2011 Jordan 15

16 Screening gproblems 1- Over referral 2-Radiation 3-Lack of parents compliance 4-Cost 16

17 = Birth, development, medical history = Any symptoms or pain = Skeletal age. = Female: Onset of menses = Family history Onset course, evolution of deformity 17

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20 Standing ( back and front) 1-any curve ( describe it) 2-loins 3- Shoulder (one elevated shoulder) 4-Skin: hi hairy patches th café au lait spots Sacral dimples Spina bifida 20

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22 5-Pelvis ( rotation, one side elevated) 6-Maturity of breasts 7- Ant. chest aymmetry 7- Axillary hair 8- Voice in male 22

23 Standing ( lateral) Kyphosis lordosisl d i 23

24 Forward dbending test 24

25 Spinal mobility : = Side bending = Traction 25

26 Spine Palpated defects Range of motion, Flexibility Rotation, Rib hump lower extremity Leg length, Deformity Pelvic obliquity Neurologic Strength, Sensation, Reflexes, Clonus Abdominal reflexes 26

27 Plumb line 27

28 Others A- Ht, Wt B- Relative proportions. C- Mental, Psychology. D-Signs of Syndromic or hereditary disorders E- Cardio-pulmonary function 28

29 1- Renal ultrasounds 2-Cardiac assesment 3-Pulmonary function test 4-Clinical photograph 5-Muscle biopsy py 6- NCS 29

30 Plain Radiographs * Indicated in all * Full length standing PA and Lateral. = Analyze Deformity, Pathology,Anomalies, Defects, Bone lesions, Quantify scoliosis, kyphosis, lordosis. Tanner staging to determine future growth 30

31 Plain Film Radiograph Initial evaluation: Standing PA and lateral films. 31

32 Plain Film Radiograph Flexibility of the curve is evaluated with supine side-bending films (may only be needed preop.) Standing PA studies are used for follow-up 32

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34 Lat. films beyond initial evaluation are not necessary unless Spondylolysis or Spondylolisthesis is suspected. Traction is used in patients ts with N.M disease with muscles Weakness /paralysis that prevents ents active sidebending. 34

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36 Approximating i Skeletal lage Risser s Sign Ossification of the iliac apophysis begins laterally (ASIS) and progresses postero-medially towards (PSIS) to eventually cap the entire iliac crest. Risser 4 Risser 5 36

37 Role of radiography in Scoliosis i Document severity Determine skeletal maturity Monitor progression Evaluate for non-idiopathic causes of scoliosis i (spinal, soft tissue, systemic pathology). Ensure adequacy of bracing / surgery 37

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40 Quantification of deformity End levels of curve Greatest degree measureable Follow up readings from same levels 40

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42 Cobb angle problems 1- Measure one plane deformity 2-Not accurate with large curves 42

43 Indications i for MRI in Scoliosis i *Suspect local pathology Tumor, Infection... *Unusual curve patterns Left thoracic Sharp angulation Unbalanced curves *N.M type curves R/O Chiari, Syrinx, Tethered cord, Diastomatomyelia 43

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46 Idiopathic Scoliosis Treatment approach: Proper curve and patient assesment 46

47 Infantile: = Many resolve spontaneously = Observe, if progressive (10-20%) Brace.!!!???? early surgery Juvenile: = Mostly observe = Brace if progressive or surgery 47

48 Onset: 4-9 y Progresses rapidly. Always look for underlying disease 48

49 Apex anterior convex epiphysiodesis Early instrumentation without fusion. 49

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51 Adolescent Idiopathic Scoliosis i Observation Curves < 20 degrees, skeletally immature. Patient near maturity, curves < 40 degrees. Bracing Immature patient t> 25 degrees Patient with progression > 10 degrees Surgery Curve ~ degrees Much growth remaining, i progressive, failed brace 51

52 for bracing to be effective * Remaining growth * Curve < 40 degrees *Proper brace, and compliance bracing can at best slow or stop progression, it does not correct a deformity 52

53 Summit brace Custom TLSO 53

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61 Surgical Treatment 50 0 When? # Failed bracing # Severe curvature # Expected progression # Beyond acceptable degree of deformity 61

62 = Arrest progression = Achieve balance of the spine = Obtain safe degree of correction = Ensure a fused spine 62

63 Old surgical correction 63

64 Old surgical correction 64

65 Old surgical correction 65

66 Posterior Pedicle Screw 66

67 1/16/2011 Jordan 67

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72 Endoscopic Surgery * Can permit much smaller incisions for surgery of the anterior spinal column. * Faster recovery er possible. * Less tissue damage. * Less blood loss possible. 72

73 Endoscopic Surgery Rl Release of fdisc Views into chest cavity With thoracoscope 73

74 Scoliosis i Kyphosis 67 0 Surgical plan: Endoscopic ant. release Post. instrumentation 1/16/2011 Jordan 74

75 Post-operative: operative: Scoliosis 40 0 Kyphosis

76 Summary Proper Screening/Evaluation = All suspicious exams X-ray evaluation. = Thorough PE, R/O non-idiopathic etiology. = All suspicious curves MRI, CT. 76

77 Treatment = Mild curves ( ) Observe = Md Moderate, progressive curves ( ) Brace = Severe, progressive (~ 50 0 ) Surgery 77