4 – Spine deformities: Difference between revisions
(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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*** By physiotherapy and exercise | *** By physiotherapy and exercise | ||
*** Surgery not required | *** Surgery not required | ||
== 42. Scoliosis with known etiology, treatment of == | |||
* Structural scoliosis is secondary in 20% of cases | |||
* Compared to idiopathic scoliosis, neuromuscular scoliosis involves | |||
** Pelvic deformities in addition to the spinal deformities | |||
** Risk of progression independent of growth (after skeletal maturity) | |||
** Several comorbidities | |||
** Neurological problems | |||
** Problems while sitting | |||
* Etiology | |||
** Neuromuscular | |||
*** = causing muscle weakness or asymmetry | |||
*** Spinal muscular atrophy | |||
*** Cerebral palsy | |||
*** Duchenne muscular dystrophy | |||
** Congenital (abnormal vertebrae) | |||
*** Wedge vertebrae | |||
*** Block vertebrae | |||
*** Hemiblock vertebrae | |||
** Syndromic | |||
*** Neurofibromatosis | |||
**** MRI should be performed to look for neurofibromas | |||
*** Marfan syndrome | |||
*** Ehlers-Danlos syndrome | |||
* Treatment | |||
** Neuromuscular scoliosis | |||
*** Growing rods until growth is finished | |||
*** Spinal fusion surgery (of Luque) | |||
** Congenital scoliosis | |||
*** Surgery to correct the congenital abnormality | |||
** Syndromic scoliosis | |||
*** Same as for adolescent idiopathic scoliosis | |||
== 51. Idiopathic structural scoliosis == | |||
* Structural scoliosis is idiopathic in 80% of cases | |||
* Adolescent idiopathic scoliosis (AIS) | |||
** 11 – 18 years | |||
** Lenke classification system | |||
*** The gold standard for classification of AIS | |||
*** Helps plan surgeries | |||
** Risser sign | |||
*** = degree of ossification of the iliac apophysis across the iliac crest | |||
*** Is used to estimate the skeletal maturity of the vertebral column and to guide treatment | |||
**** -> more mature = less risk of scoliosis progressing | |||
**** -> less mature = more risk of scoliosis progressing | |||
**** Spinal fusion surgery can only be performed on those with mature skeleton | |||
***** If Risser 2 or lower -> conservative treatment | |||
***** If Risser 3 or higher -> spinal fusion surgery | |||
*** Risser 1 = 25% of the iliac crest is ossified | |||
*** Risser 2 = 50% | |||
*** Risser 3 = 75% | |||
*** Risser 4 = 100% of the iliac crest is ossified | |||
*** Risser 5 = the iliac crest is fused to ileum | |||
** Skeletal maturity can also be planned based on menarche | |||
*** We say that 2 years after menarche the skeleton is mature enough for spinal fusion surgery | |||
** Poor prognostic factors (factors which increase risk of curve progression) | |||
*** These factors are important to determine how often a check-up should be performed | |||
*** Female | |||
*** Age of onset | |||
*** Greater Cobb angle | |||
*** Scoliosis of upper spine | |||
*** Bigger vertebral rotation | |||
*** Bigger rib-vertebral angle difference (RVAD) | |||
** Treatment | |||
*** Conservative | |||
**** Used for Risser 2 and below while waiting for skeletal maturity, and for < 50 degree Cobb | |||
**** Schroth therapy | |||
***** = special 3D training exercises | |||
***** These exercises not only stops progression but can cause regression of curve | |||
**** Cheneau brace | |||
***** Should be worn for 20 hours per day | |||
***** Must be combined with physical exercise | |||
***** The brace helps stopping the progression but does not cause regression | |||
*** Surgery | |||
**** Posterior instrumented fusion with direct vertebral rotation | |||
***** A form of spinal fusion surgery | |||
***** Gold standard | |||
***** Involves placement of screws and rods | |||
**** Osteotomies | |||
***** On rigid spines | |||
*** Cobb angle 15 – 20 degrees | |||
**** Night-time brace + Schroth therapy | |||
**** Only observation (if non-progressive curve) | |||
*** Cobb angle 20 – 40 degrees | |||
**** Cheneau brace + Schroth therapy | |||
*** Cobb angle 50 – 65 degrees -> Surgery | |||
**** Surgery at this stage corrects the cosmetic problem and prevents later back pain | |||
*** Cobb angle > 65 degrees -> Surgery | |||
**** Surgery at this stage not only corrects the cosmetic problem and prevents later back pain, but also prevents severe cardiorespiratory complications | |||
* Early onset scoliosis | |||
** Treatment is not based on fusion (as in AIS) but rather uses unilateral growing rods | |||
** Many cases resolve spontaneously | |||
[[Category:Orthopaedics (POTE course)]] | [[Category:Orthopaedics (POTE course)]] |
Latest revision as of 11:04, 27 August 2024
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
42. Scoliosis with known etiology, treatment of
- Structural scoliosis is secondary in 20% of cases
- Compared to idiopathic scoliosis, neuromuscular scoliosis involves
- Pelvic deformities in addition to the spinal deformities
- Risk of progression independent of growth (after skeletal maturity)
- Several comorbidities
- Neurological problems
- Problems while sitting
- Etiology
- Neuromuscular
- = causing muscle weakness or asymmetry
- Spinal muscular atrophy
- Cerebral palsy
- Duchenne muscular dystrophy
- Congenital (abnormal vertebrae)
- Wedge vertebrae
- Block vertebrae
- Hemiblock vertebrae
- Syndromic
- Neurofibromatosis
- MRI should be performed to look for neurofibromas
- Marfan syndrome
- Ehlers-Danlos syndrome
- Neurofibromatosis
- Neuromuscular
- Treatment
- Neuromuscular scoliosis
- Growing rods until growth is finished
- Spinal fusion surgery (of Luque)
- Congenital scoliosis
- Surgery to correct the congenital abnormality
- Syndromic scoliosis
- Same as for adolescent idiopathic scoliosis
- Neuromuscular scoliosis
51. Idiopathic structural scoliosis
- Structural scoliosis is idiopathic in 80% of cases
- Adolescent idiopathic scoliosis (AIS)
- 11 – 18 years
- Lenke classification system
- The gold standard for classification of AIS
- Helps plan surgeries
- Risser sign
- = degree of ossification of the iliac apophysis across the iliac crest
- Is used to estimate the skeletal maturity of the vertebral column and to guide treatment
- -> more mature = less risk of scoliosis progressing
- -> less mature = more risk of scoliosis progressing
- Spinal fusion surgery can only be performed on those with mature skeleton
- If Risser 2 or lower -> conservative treatment
- If Risser 3 or higher -> spinal fusion surgery
- Risser 1 = 25% of the iliac crest is ossified
- Risser 2 = 50%
- Risser 3 = 75%
- Risser 4 = 100% of the iliac crest is ossified
- Risser 5 = the iliac crest is fused to ileum
- Skeletal maturity can also be planned based on menarche
- We say that 2 years after menarche the skeleton is mature enough for spinal fusion surgery
- Poor prognostic factors (factors which increase risk of curve progression)
- These factors are important to determine how often a check-up should be performed
- Female
- Age of onset
- Greater Cobb angle
- Scoliosis of upper spine
- Bigger vertebral rotation
- Bigger rib-vertebral angle difference (RVAD)
- Treatment
- Conservative
- Used for Risser 2 and below while waiting for skeletal maturity, and for < 50 degree Cobb
- Schroth therapy
- = special 3D training exercises
- These exercises not only stops progression but can cause regression of curve
- Cheneau brace
- Should be worn for 20 hours per day
- Must be combined with physical exercise
- The brace helps stopping the progression but does not cause regression
- Surgery
- Posterior instrumented fusion with direct vertebral rotation
- A form of spinal fusion surgery
- Gold standard
- Involves placement of screws and rods
- Osteotomies
- On rigid spines
- Posterior instrumented fusion with direct vertebral rotation
- Cobb angle 15 – 20 degrees
- Night-time brace + Schroth therapy
- Only observation (if non-progressive curve)
- Cobb angle 20 – 40 degrees
- Cheneau brace + Schroth therapy
- Cobb angle 50 – 65 degrees -> Surgery
- Surgery at this stage corrects the cosmetic problem and prevents later back pain
- Cobb angle > 65 degrees -> Surgery
- Surgery at this stage not only corrects the cosmetic problem and prevents later back pain, but also prevents severe cardiorespiratory complications
- Conservative
- Early onset scoliosis
- Treatment is not based on fusion (as in AIS) but rather uses unilateral growing rods
- Many cases resolve spontaneously