18th International Scientific Meeting of the VCFS Educational Foundation Steven M. Reich, MD. July 15-17, 2011 New Brunswick, New Jersey USA

Transcription

1 18th International Scientific Meeting of the VCFS Educational Foundation Steven M. Reich, MD July 15-17, 2011 New Brunswick, New Jersey USA

2 SCOLIOSIS AND ITS TREATMENT Steven M. Reich, MD Assistant Clinical Professor, Department of Orthopaedic Surgery Robert Wood Johnson Medical School - UMDNJ New Brunswick, NJ, USA (732)

3 Definitions Normal Spine: Straight in the frontal plane Sagittal plane Thoracic kyphosis averages deg Lumbar lordosis averages deg

4 Scoliosis 3 plane deformity Frontal/Coronal: lateral deviation from midline Sagittal: kyphosis/lordosis, most idiopathics are relatively hypokyphotic Axial/Rotational: greatest at the apex of curve Definitions

5 Etiology Remains largely unknown. Genetic: Scoliosis in 11% of 1 st degree relatives of pts with idiopathic scoliosis Twin studies: monozygotic 73% concordance, dizygotic 36% concordance Still don t know gene(s) or gene products Over 120 genes implicated Certainly multifactorial

6 Curve location (SRS): Classification

7 Classification Age at onset (idiopathic):

8 Classification Etiology Idiopathic Congenital Neuromuscular Syndrome-related

9 Idiopathic Scoliosis Curve greater than 10 degrees Diagnosis of exclusion 80% of all scoliosis is idiopathic Prevalence: per 100 By age group: Infantile 1%, Juvenile 10%, Adolescent 89%

10 Adolescent Idiopathic Scoliosis Female-to-Male Ratio: 1:1 1.4:1 5.4:1 7.2:1 Curves 6-10 o Curves o Curves exceeding 21 o but no treatment Curves requiring orthopaedic intervention

11 Evaluation/Diagnosis

12 Clinical Work-up School Screening History Physical Exam Imaging

13 History What prompted the visit? Back pain? Recent growth Pubertal changes (onset of menses) Family history Neurologic symptoms: walking, running, climbing stairs, numbness/tingling, bowel/bladder Review of systems: cardiac, pulmonary, renal.

14 OBSERVE first! Trunk shape and balance: Physical Exam Shoulders: Asymmetry of shoulder height or scapulae Pelvis: waist line, leg lengths Trunk shift: Plumb line

15 Physical Exam

16 Physical Exam FORWARD BEND TEST First described by Adams, 1865 Bend forward at waist, knees straight, palms together Trunk rotation, kyphosis

17 Physical Exam FORWARD BEND TEST Scoliometer: angle of trunk rotation (ATR) ATR 5-7 deg = Cobb deg Refer if: Immature growing children if Scoliometer angle exceeds 7 o angle of trunk rotation

18 Physical Exam NEUROLOGIC EXAM Balance/Motor: walk, toe/heel walk, squat deeply, single leg hop Sensation Reflexes DTR Abdominal: if abnormal, strongly consider MRI to look for intraspinal pathology

19 Physical Exam SKIN EXAM Café au lait spots, axillary freckling (NF) Dimpling or hairy patch in lumbosacral area Skin or joint laxity

20 LIMB LENGTH May be a compensatory curve for rebalancing No rotational deformity Lumbar curve toward the side of short leg Balance out with blocks Physical Exam

21 Imaging Standing PA on 36 x 14 cassette Standing lateral on all new pts

22 Imaging Reading a film Bony abnormalities: Congenital: wedge, hemivertebrae, bar, bifid Pedicles bilaterally, distance between (intraspinal mass) Lucency/lytic process Curve measurement Skeletal maturity

23 Cobb angle: Imaging

24 Imaging Apex: center, most laterally deviated disc or vertebra Apical vertebra(e): most horizontal at apex End vertebrae: proximal and distal extent, Cobb Central sacral vertical line: bisects the sacrum

25 Imaging Risser Staging: Iliac crest apophysis ossifies lateral to medial Fusion to body of ilium = fusion of vertebral ring apophysis = end of spinal growth Triradiate cartilage: Closes before Risser 1 Closes at maximal spinal growth

26 Decision-Making

27 Adolescent Idiopathic Scoliosis Risk factors for progression: Curve magnitude: at diagnosis Remaining skeletal growth Menarche: starts 1 year after most rapid growth Risser: Risser % progress, Risser 3 <10% Curve location: curves with apex above T12 more likely to progress than isolated lumbar Gender: female > male

28 Selection of Treatment Curve < 25 deg: Mature: no further f/u Immature: observe, re-examine 6-12 months Curve deg: Mature: no treatment, but f/u 1 year to check for progression Immature: risk for progression, consider non-operative treatment Curve >50 deg: Consider operative treatment

29 Treatment Choices Curve Size Risser 0, Premen Risser 1, 2 Risser 3-5 < 25 o Observe Observe Observe 25 o 45 o Brace Brace Observe > 50 o Surgery Surgery Surgery

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31 Curve Progression Percentage of Curves that Progress Risser Grade Curves 5-19º Curves 20-29º 0 or 1 22% 68% 2, 3, or 4 2% 23% *Lonstein JE, Carlson JM. JBJS 1984

32 Nonoperative Treatment Underlying principle: modify spinal growth by applying an external force Only useful in pt with substantial growth remaining: Premenarchal, Risser 0,1,2 Upper limit approximately 45 deg Goal: maintain the curve at the degree of severity at the onset of bracing

33 Nonoperative Treatment Indications: deg curve that has progressed more than 5 deg in a pt with at least 1 year of growth remaining deg curve in immature pt at 1 st visit Occasionally, increasing rib prominence without change in curve magnitude

34 Brace Types Underarm braces: Boston: more conspicuous, better appearance, better compliance? Charleston: nighttime bending brace Attempts to correct Lumbar curves deg

35 Boston Brace Types

36 Charleston Brace Types

37 Nonoperative Treatment Brace wear / compliance: Failure: image, self-esteem, pain, poor fit, heat, family environment 16 hour vs. 23 hour schedule, supine vs. standing Dose-dependent relationship between time/day in brace and success in preventing progression (SRS, 1997)

38 Bracing Efficacy Effectiveness of brace requires Brace Wear! A good orthotist Regular follow-up Studies in support of bracing offer only Level 3 or Level 4 evidence but they are large, well structured studies Currently 14 institutions are involved in a Level 1 Study.

39 Goals Surgery Prevent Curve Progression Correction of the curve (partial) Methods of surgery Instrumentation Corrects curve Holds curve until fusion Anterior (front of the spine) Posterior (back of the spine) - most common Combined Downside of surgery Fusion or stiffening of the spine Important to preserve lumbar motion

40 The olden days

41 Posterior

42 Posterior

43 115º (82º) Posterior

44

45 Anterior

46 Thoracoscopic Technique

47 54

48 Discussion

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50 Complications Infection 1% of patients Requires surgical debridment and IV antibiotics 50% retain implants after fusion Neurologic injury 1 in 3000 isolated nerve injury 1 in 10,000 paraplegia Failure to heal (pseudarthrosis) Rare in era of pedicle screws

51 Congenital Scoliosis

52 Congenital Scoliosis Definition: Abnormally formed vertebral elements and the altered vertebral shape produces deviations in spinal alignment Secondary to deficiencies before 48 days of gestation Cardiac and urologic abnormalities

53 Congenital Scoliosis Classification:

54 Congenital Scoliosis Risk factors for progression: Thoracic location Multiple hemivertebrae and a convex unilateral bar opposite the hemivertebrae

55 Congenital Scoliosis Nonoperative treatment: Bracing NOT effective for primary congenital curves Could be used for compensatory curves

56 Congenital Scoliosis Surgical Treatment: Usually required earlier than idiopathic Unsegmented bar with contralateral hemivertebra may be indication for surgery at time of diagnosis Goal of surgery is to limit progression

57 Summary Scoliosis is a 3-dimensional deformity Vast majority are idiopathic with unknown etiology..genetics Observe the back and make sure pelvis is level Will it progress? Curve magnitude Remaining growth (Menarche, Risser) Braces are low-profile and DO work (if they are worn) Surgery is safer than ever When in doubt.refer!

58 THANK YOU