Gregory M Yoshida, MD. Lateral curvature of the spine in the coronal plane > 10 degrees on an upright film

Transcription

1 Gregory M Yoshida, MD Lateral curvature of the spine in the coronal plane > 10 degrees on an upright film

2 Measurement Angle made by the endplates of the two most tilted vertebra from horizontal Cobb angle Angle formed by the intersection of lines drawn perpendicular to the endplates of most tilted vertebra

3 Digital systems have built in measurement programs which eliminate the need to use the Cobb method Congenital Idiopathic Neuromuscular Degenerative Failure of formation Hemivertebra Failure of segmentation Bar Combination of both Scrambled egg spine

4 Hemivertebra One pedicle Grows like fan opening causing scoliosis Can be incarcerated No growth plates Static deformity Bar Disc space does not form on one side Tethers vertebra together causing scoliosis Bars worse than hemis Bar with contralateral hemi Ipsilateral bars Ipsilateral hemis Bar Hemi

5 Bracing ineffective Fusion if any progression Random occurrence No increased risk of subsequent child having disorder Associated with other congenital anomalies VACTERL Vertebral Anal atresia Cardiac Tracheo-esophageal Renal/radial Limb deficiencies (radial)

6 Infantile Juvenile Adolescent 0 2 years Male > female Left thoracic Resolves spontaneously More common in the United Kingdom Nannies place infants left side down for sleep

7 5 8 years of age Similar to adolescent More likely to require surgical intervention than adolescent 9-16 years of age 3 in 100 children 1 in 100 children with scoliosis require surgery Genetic predisposition Girls : boys 2.5:1 Painless Painful scoliosis must be investigated Tumor Infection Bone scan

8 Actually a three dimensional deformity Vertebral bodies rotate towards convexity of curve Physical exam Adam s position Forward flexion to 90 Rib hump Scoliometer 7 degrees warrants X-ray Neurologic exam Standard motor and sensory lower extremities Abdominal reflexes Patient supine Scratch four quadrants of abdomen Navel moves to side of stimulus

9 Asymmetric abdominal reflex First sign of syringomyelia MRI Right thoracic/thoracolumbar curve (apex) most common Left lumbar Left thoracic rare MRI indicated 28% incidence of associated diastematomyelia

10 Natural history Can progress 1 3 degrees/month Factors for progression Young chronologic age Premenarche Female Risser 0 Degree of curvature Menarche Occurs on tail end of growth spurt 2 years of growth left on average Minimal progression after skeletal maturity Female Girls are 5 times more likely to progress than boys at the same curvature Risser sign Ossification of the iliac apophysis Risser 2 correlates with menarche

11 Larger curves more likely to progress degrees Observation (q 6 mo) degrees Observation (1 st presentation) Brace (if progressed from a lesser degree) Progression is increase of 5 degrees or more 31 degrees or greater Brace If patient is post menarchal observation is usually indicated unless curve >45

12 No other modalities beneficial PT DC TENS Boston TLSO Must be worn 18 hours a day continuously Apex T6 or lower Nighttime bending brace Milwaukee brace Prevents progression No correction Ineffective once a curve reaches 45 degrees

13 Curves that progress despite bracing or present 45 degrees or greater Fusion PFT changes at 60 Clinical shortness of breath at 90 Early death (cor pulmonale) at Curves progess 1-3 degrees per year after maturity Female skeletally mature at 16 with a 45 degree curve Progresses 3 degrees per year Will hit 120 in 25 years at age 41 Early death

14 Curve due to abnormal/absent neuromuscular function of trunk Classically a long C-shaped curve from neck to pelvis Minimal rotatory component Cerebral palsy Spinal cord injury Duchenne muscular dystrophy Polio

15 Any child who incurs a complete spinal cord injury before puberty will develop scoliosis Once a Duchenne patient becomes wheelchair bound, fusion should be performed ASAP if indicated Observation is usual treatment Bracing is an option in patients under 10 years Follow AIS guidelines Relative indications for fusion Seating balance Pressure ulcers/pelvic obliquity

16 Ethical issues Non-communicative patients Cookie test Non-sitter/non-ambulator T2-Sacrum Asymmetric collapse of the spine with aging Left lumbar most common Factors for progression > 30 degrees Intercrest line below L4-5 Laterolisthesis

17 Laterolisthesis Lateral displacement of superior vertebra of a motion segment to the inferior one In the long run self limiting Ribs rest on iliac crest preventing further progression Observation Symptomatic treatment NSAID PT ESI Facet blocks

18 Operative intervention may help if there is associated stenosis Operative treatment Large scale surgery High complication rate Hardware failure Low success rate

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