Scoliosis: Orthopaedic Perspectives
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1 Scoliosis: Orthopaedic Perspectives Scott B. Rosenfeld, MD Division of Pediatric Orthopaedic Surgery Texas Children s Hospital Page 0 xxx00.#####.ppt 9/23/2012 8:26:24 AM
2 I have no disclosures Disclosures Page 1 xxx00.#####.ppt 9/23/2012 8:26:25 AM
3 Types of Scoliosis -How imaging is used in each Plan for this talk What I am looking to learn from my imaging studies How I make treatment decisions based on imaging Page 2 xxx00.#####.ppt 9/23/2012 8:26:26 AM
4 Reality Vast majority of scoliosis cases only require plain radiographs Page 3 xxx00.#####.ppt 9/23/2012 8:26:27 AM
5 Idiopathic (80%) - Infantile 2mo-3yr - Juvenile 3yr-10yr - Adolescent >10yr Types of Scoliosis Congenital Neuromuscular - CP, spina bifida, SCI, DMD Syndromic Marfans, NF Thoracogenic Page 4 xxx00.#####.ppt 9/23/2012 8:26:28 AM
6 Plain radiographs Imaging in Scoliosis -Standing PA and lateral Entire spine on one film Entire pelvis visible Risser sign Tri-radiate cartilage -Hand for bone age -Bending radiographs Page 5 xxx00.#####.ppt 9/23/2012 8:26:29 AM
7 Risser Sign Page 6 xxx00.#####.ppt 9/23/2012 8:26:30 AM
8 Hand Xray for bone age Page 7 xxx00.#####.ppt 9/23/2012 8:26:31 AM
9 Page 8 xxx00.#####.ppt 9/23/2012 8:26:32 AM
10 MRI - Used to look for intra-spinal abnormalities Imaging in Scoliosis - Things that could get us into trouble in surgery Syrinx, tethered cord, Chiari malformation, diastametamyelia - Early onset scoliosis 20% - Congenital scoliosis 20% - Left thoracic curves - Rapid progression Page 9 xxx00.#####.ppt 9/23/2012 8:26:33 AM
11 CT Imaging in Scoliosis -Define bony anatomy Congenital scoliosis -Check pedicle screw position Page 10 xxx00.#####.ppt 9/23/2012 8:26:34 AM
12 13 year old female presents with scoliosis Idiopathic Scoliosis Postmenarchal Curve has progressed over last 2 years Unhappy with appearance of her spine Page 11 xxx00.#####.ppt 9/23/2012 8:26:34 AM
13 63 45 Page 12 xxx00.#####.ppt 9/23/2012 8:26:36 AM
14 Page 13 xxx00.#####.ppt 9/23/2012 8:26:37 AM
15 Scoliosis Treatment Depends on how big it is and how big its going to get <25 = Observe Controversial lots of potential options - Immature = consider brace - Mature = observe >50 = spinal fusion Page 14 xxx00.#####.ppt 9/23/2012 8:26:38 AM
16 Plan My Surgery There are 2 curves here Which one do I fuse? Need bending films Structural vs non-structural curves - Significance: Structural curves may need to be included in the fusion - Criteria for structural Larger is always structural Rotated = structural >25 on bending films = structural Page 15 xxx00.#####.ppt 9/23/2012 8:26:40 AM
17 13 35 Page 16 xxx00.#####.ppt 9/23/2012 8:26:40 AM
18 Choosing fusion levels Page 17 xxx00.#####.ppt 9/23/2012 8:26:41 AM
19 Page 18 xxx00.#####.ppt 9/23/2012 8:26:42 AM
20 Page 19 xxx00.#####.ppt 9/23/2012 8:26:43 AM
21 Page 20 xxx00.#####.ppt 9/23/2012 8:26:44 AM
22 Didn t follow the center sacral line rule Page 21 xxx00.#####.ppt 9/23/2012 8:26:46 AM
23 6 year old female presents with spinal curvature Congenital Scoliosis Stands with significant lean to the right Waistline asymmetry Page 22 xxx00.#####.ppt 9/23/2012 8:26:47 AM
24 Classification -Failure of formation Hemivertebra Congenital Scoliosis -Failure of segmentation Unilateral bar Block vertebra -Combination Need advanced imaging *Hedequist Page 23 xxx00.#####.ppt 9/23/2012 8:26:48 AM
25 Other things to think about Congenital Scoliosis -VACTERL syndrome Vertebral Anal atresia Cardiac Tracheo-Esophageal fistula Renal Limb -Intraspinal anomalies Page 24 xxx00.#####.ppt 9/23/2012 8:26:49 AM
26 Congenital Scoliosis How I think about treatment -Is it going to progress? Highest risk is hemivertebra with contralateral bar Lowest risk is block vertebra -I need to know from advanced imaging what the anatomy is *Hedequist Page 25 xxx00.#####.ppt 9/23/2012 8:26:50 AM
27 How I think about treatment -Where is it located? Cervical spine Thoracic spine Lumbar spine Congenital Scoliosis -Determines my treatment approach Fusion in situ Hemivertebra excision Page 26 xxx00.#####.ppt 9/23/2012 8:26:51 AM
28 Looks like a right hemiverebra between L1 and L2 -I want a 3D CT to define the anatomy Congenital Scoliosis -MRI to look for intraspinal anomalies -Heart, kidneys evaluated Page 27 xxx00.#####.ppt 9/23/2012 8:26:52 AM
29 Page 28 xxx00.#####.ppt 9/23/2012 8:26:53 AM
30 Right sided hemivertebra between L1 and L2 with no contralateral bar Congenital Scolosis Treatment options -In situ fusion Limited correction ability -Hemivertebra excision with short segment fusion Page 29 xxx00.#####.ppt 9/23/2012 8:26:54 AM
31 Hemivertebra excision and short segment fusion Congenital Scoliosis Page 30 xxx00.#####.ppt 9/23/2012 8:26:55 AM
32 Page 31 xxx00.#####.ppt 9/23/2012 8:26:56 AM
33 Page 32 xxx00.#####.ppt 9/23/2012 8:26:57 AM
34 Page 33 xxx00.#####.ppt 9/23/2012 8:26:58 AM
35 Page 34 xxx00.#####.ppt 9/23/2012 8:26:59 AM
36 Page 35 xxx00.#####.ppt 9/23/2012 8:27:00 AM
37 Page 36 xxx00.#####.ppt 9/23/2012 8:27:02 AM
38 Early Onset Scoliosis Definition Onset prior to age 5 y.o. Significance high risk of progression T1-S1 growth velocity -0-5y.o.: 2.2cm/yr -5-10y.o.: 1cm/yr -Puberty: 1.8cm/yr Page 37 xxx00.#####.ppt 9/23/2012 8:27:03 AM
39 High risk of progression -Very large curve magnitude -Severe cosmetic deformity -Significant pulmonary dysfunction Early Onset Scoliosis Page 38 xxx00.#####.ppt 9/23/2012 8:27:04 AM
40 Early Onset Scoliosis Pulmonary Dysfunction -Bronchial tree and alveoli not fully developed until 8y.o. -Thoracic volume at 10y.o. only 50% of adult volume 4 year old with significant deformity loses many years of important pulmonary development Page 39 xxx00.#####.ppt 9/23/2012 8:27:05 AM
41 Treatment Options -Growth Sparing Early Onset Scoliosis Serial casting (Risser) Growing rods VEPTR Tethering/Stapling -Arthrodesis Not good for pulmonary development Page 40 xxx00.#####.ppt 9/23/2012 8:27:05 AM
42 Early Onset Scoliosis 4 year old presents with large spinal deformity No PMH Neurologically normal Page 41 xxx00.#####.ppt 9/23/2012 8:27:06 AM
43 What imaging I order - Standing PA and lateral full length scoli xrays Early Onset Scoliosis What I want to know: How big is the curve? Are there congenital components? Hemivertebra? Rib fusion? Kyphotic or lordotic? Page 42 xxx00.#####.ppt 9/23/2012 8:27:07 AM
44 Early Onset Scoliosis Advanced imaging -CT vs MRI -I need to know: Is that a congenital component? Are there any intra-spinal anomalies? Chiari Syrinx Tether Diastametamyelia Page 43 xxx00.#####.ppt 9/23/2012 8:27:08 AM
45 This is where I really need the read from the radiologist Prevent me from getting into trouble Page 44 xxx00.#####.ppt 9/23/2012 8:27:09 AM
46 Page 45 xxx00.#####.ppt 9/23/2012 8:27:10 AM
47 Decision making -Young child Early Onset Scoliosis -Lots of growth remaining -Large curve and progressing -Normal anatomy -No intraspinal abnormality Page 46 xxx00.#####.ppt 9/23/2012 8:27:11 AM
48 Hybrid expandable construct Early Onset Scoliosis - Combination of VEPTR and growing rods - Minimal exposure of spine Cephalad attachments to ribs Prevents unwanted spine fusion - Expansion every 9 months - Allow for thoracic growth - Definitive fusion around 11y.o. Page 47 xxx00.#####.ppt 9/23/2012 8:27:12 AM
49 Thank you Page 48 xxx00.#####.ppt 9/23/2012 8:27:13 AM
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