4 – Spine deformities

Revision as of 11:03, 27 August 2024 by Nikolas (talk | contribs) (Created page with "== 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...")
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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
    • 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
    • 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
  • 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

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

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
  • 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