4 – Spine deformities
Basics of spine
- Curvatures
- Lordosis – concave (inward)
- Kyphosis – convex (outward)
- Scoliosis – deformity in all 3 planes (not just sideways)
- Lateral curvature in the coronal plane
- Lordotic deviation in the sagittal plane
- Vertebral rotation in the horizontal plane
- Normal:
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
Basics of scoliosis
- Scoliosis – deformity in all 3 planes (not just sideways)
- Lateral curvature in the coronal plane
- Lordotic deviation in the sagittal plane
- Vertebral rotation in the horizontal plane
- Most patients with scoliosis have small curves without progression
- Scoliosis causes a characteristic “rib hump” when bending over
- Due to the rotation of the vertebrae the ribs will be pushed posteriorly
- Scoliosis is a dynamic deformity – annual (or more frequent) follow-ups are mandatory until bony maturation
- Categorization of scoliosis based on onset
- Congenital (due to vertebral malformations)
- Early onset (< 9 years)
- Infantile (< 3 years)
- Boys > girls
- 80% spontaneously resolve
- Juvenile (3 – 9 years)
- Boys = girls
- Infantile (< 3 years)
- Adolescent (11 – 18 years) (= adolescent idiopathic scoliosis, AIS)
- Boys < girls (1:7)
- Adult
- Rare
- Due to degenerative disease, trauma, etc.
- Categorization of scoliosis based on vertebral rotation
- Structural scoliosis – with vertebral rotation
- Functional scoliosis – without vertebral rotation
- See topic 30
- Diagnosis
- Scoliometer
- = a tool which measures the angle of trunk rotation
- Coronal balance
- Patients with scoliosis will compensate in the coronal plane by laterally moving their head or pelvis
- Computers measure the degree of compensation of scoliosis based on x-ray
- If the straight line from C7 does not land between the buttocks, the scoliosis is decompensated to one side
- During treatment the goal is to put the spine into normal coronal and sagittal balance
- Sagittal balance
- Patients with scoliosis will compensate in the sagittal plane by anteriorly or posteriorly moving their head or pelvis
- Computers measure this as well
- X-ray
- Of full spine (base of skull to pelvis)
- To check the pelvic compensation as well
- AP and lateral views
- While standing and while bending laterally
- TRuGA (traction x-ray under general anaesthesia)
- X-ray while the head and pelvis are pulled in opposite directions
- Shows how rigid the curve is
- Of full spine (base of skull to pelvis)
- MRI
- Only if red flags (like unusual curve) are suspected
- Can detect tethered cord, syringomyelia, dyasthematomyelia, Chiari malformation
- If these conditions are not detected before scoliosis surgery paralysis or severe complications can develop
- 3D CT
- If congenital vertebral malformations are suspected
- Scoliometer
- How to measure scoliosis -> measure Cobb angle
- Cobbs angle is the angle between the following two lines:
- A line parallel to the superior endplate of the highest affected vertebra
- A line parallel to the inferior endplate of the lowest affected vertebra
- A Cobb angle of > 90 degrees has high risk of cardiac or respiratory disease, so surgery is always indicated
- Depending on the type of scoliosis surgery may be indicated at smaller degrees too
- Cobbs angle is the angle between the following two lines:
18. Scheuermann’s Disease
- = Scheuermann kyphosis
- Epidemiology
- Male > female (2:1)
- Prevalence 4 – 8%
- Starts around puberty
- Pathology
- Avascular necrosis of the vertebral body apophysis
- Clinical features
- Usually affects thoracic spine
- Rigid, progressive, and painful hyperkyphosis
- Kyphosis increases when bending forward
- Subacute back pain
- Signs on X-ray
- Regular hyperkyphosis (Cobb angle > 40 degrees)
- Wedging of vertebral bodies
- Irregular endplates
- Schmorl herniation
- Long and narrow vertebral bodies (compared to normal cube shape)
- Treatment
- Cobb angle 40 – 70 degrees
- Schroth therapy and Gschwend brace
- Cobb angle 70 – 80 degrees
- Surgery if pain is dominant
- Cobb angle > 80 degrees
- Surgery
- Cobb angle 40 – 70 degrees
30. Functional scoliosis, postural deformities
- Functional scoliosis = A structurally normal spine that appears to have a lateral curve
- The spine appears scoliotic due to an underlying problem like:
- Limb length discrepancy
- Antalgic posture
- Disc herniation
- Sacroiliitis
- Appendicitis
- Etc.
- Hysteriform scoliosis
- Very rare
- Some kind of psychosomatic problem in young females?
- There is NO rotation of the vertebral bodies, unlike in structural (normal) scoliosis
- -> No rib hump when bending over
- -> Scoliosis disappears in supine position or when bending to the side
- The spine appears scoliotic due to an underlying problem like:
- Postural deformities
- Normal posture of spine
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
- Lumbosacral kyphosis
- Postural deformities
- Excessive thoracic kyphosis
- Excessive lumbar lordosis
- Treatment
- By physiotherapy and exercise
- Surgery not required
- Normal posture of spine