DISSERTATION SUBMITTED TO UNIVERSITY OF … Sudhir Seth.pdf · DISSERTATION SUBMITTED TO UNIVERSITY...

MANAGEMENT OF SCOLIOSIS

A STUDY DONE AT SAFDARJUNG HOSPITAL DELHI

DISSERTATION SUBMITTED TO

UNIVERSITY OF SEYCHELLES

AMERICAN INSTITUTE OF MEDICINE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

M.Ch (Orthopaedic Surgery)

By

DR. SUDHIR SETH

Orthopaedic Surgeon

November 2011

Boolean Education (A division of Quexst Solutions Pvt. Ltd)

4th Floor Wing B, Gopal House, Kothrud, Karve Road, Pune-411029 (India), Tel: + 91-20-66858100 Fax: +91-20-41216346.

MANAGEMENT OF SCOLIOSIS

BACKGROUND

Scoliosis is derived from a Greek word ‘SKOLIOS’ meaning curvature. Scoliosis remains as one of the important and difficult orthopedic problems and an unsolved mystery. Management of this unpredictable problem of teenage is very difficult and unpredictable. Management is divided broadly into CONSERVATIVE( observation-exercises-orthrosis) and SURGERY.

METHOD

Fifty consecutive patients of scoliosis were treated using conservative or surgical methods.

RESULTS

Fifty cases of scoliosis were treated over one year, of which 26 patients were on observation, exercises and braces while 24 patients were operated; of these 24 patients, 14 patients had posterior spinal fusion and 10 had Harrington Instrumentation with posterior spinal fusion.

Congenital scoliosis was the commonest cause accounting for 38%

Average age of seeking advice was 14.8 years.

Males were 54% while females were 46% of the series.

Average correction achieved was 23.2%

30.7% correction was achieved after instrumentation surgery, while it was meager 2.6% after simple fusion.

Rib hump resection achieved good cosmetic correction.

Allogenic bone graft mixed with autogenous graft gave good outcome.

CONCLUSION

Early surgery especially in advancing curvature gives good and lasting results.

KEYWORDS

Scoliosis, Congenital Scoliosis, Neuromuscular Scoliosis, Harrington Instrumentation, Posterior Spinal Fusion.



INTRODUCTION

Scoliosis is defined as a rotatory lateral curvature; tilt or angular deviation of the spine from its normal straight course.

SCOLIOSIS RESEARCH SOCIETY- CLASSIFICATION

1) Idiopathic 2) Congenital 3) Neuromuscular 4) Curve because of Neurofibromatosis 5) Mesenchymal- Marfan’s Syndrome 6) Trauma- fractures, radiation, surgery 7) Secondary to irritative phenomenon 8) Others like metabolic, nutritional, endocrinal

TREATMENT

1) Observation 2) Orthrosis 3) Operation

OBSERVATION

Observation with exercises in early stage of scoliosis is very important to improve posture and to strengthen the muscles.

ORTHOSIS

Orthrosis or braces are very important to halt the progression of the disease and to allow healing and maturation of Arthrodesis after surgery.



PRE OPERATIVE TRACTION



ORTHOSIS



SURGERY

1) Posterior Spinal Fusion after achieving pre-operative correction by traction. 2) Posterior spinal fusion with Harrington Instrumentation. 3) Luques segmental spinal instrumentation and Galveston’s Technique for L Rod

Insertion(L.R.I.) 4) Rib resection. 5) Epyphyseodysis- Roaf’s Technique. 6) Anterior spinal surgery- Dwyer’s Instrumentation. 7) Dwyer’s Instrumentation and Zielke’s Instrumentation.

MATERIALS AND METHODS

Fifty cases of scoliosis were studied over 5 years at C.I.O. Safdarjung Hospital. All cases were worked up in the Out Patient Department with details of history, examination and investigations. Detailed physical examination of all patients was done.

Neurofibromatosis, Marfan’s Syndrome, Neuromuscular diseases and other congenital anomalies were ruled out. Detailed investigations like X-rays, CT Scans, blood tests, urine test, pulmonary function tests, electrophysiological test, muscle charting were done in selected patients. All patients were classified etiologically and severity wise.

Treatment of patients was divided into 3 groups-

1) Observation group- Observation was mean for curves measuring less than 20o

Those with no structural changes in the spine

And those predicted and resolving infantile curves by Mehta’s Method.

During observation the scrutiny was kept for curve progression and patients were advised postural exercises to check progression.

2) Orthosis Treatment- Was advised for curves measuring 30o to 50o.

For skeletaly immature patients



For curves of 20o showing an alarming progression during observation period

For curves of 20o showing structural change.

3) Surgery Group-

Surgery was taken up for cases:

for progressive curves and/or those above 50o.

when orthosis had failed to check the progression

patients who had completed skeletal maturity but leaving the orthrosis will again cause progression

congenital scoliosis caused by unfermented bar and unbalanced Hemi vertebrae showing galloping progression.

After a detailed pre-operative work-up and investigations, a mandatory course of pre-operative correction was done by

o Cotrel’s Static Traction o Cotrel’s Dynamic Traction o Halo femoral technique

Surgeries that were performed were

-Simple posterior fusion

-Harrington Instrumentation with posterior spinal fusion

-Rib resection for cases where rib hump exists. This is usually done before the above two surgeries.

Modified Hibb’s Technique of posterior spinal fusion with Moe’s Technique of facet joint fusion was done.

Harrington Instrumentation was done as a distraction rod to correct the curves. In three cases of Paralytic Scoliosis with Pelvic obliquity a sacral rod was used for curves going to the pelvis. Bone graft was both autogenous and allogenic.

POSTOPERATIVELY patients with Harrington Instrumentation were nursed in a posterior plaster shell. Patients who had no instrumentation were given a body cast after 15 days of surgery after stitch removal.

In young patients autogenic graft was insufficient, so deep freeze dried stored allogenic graft was used.



FOLLOW UP. On subsequent visits a 60 right and left oblique view XRAYS were done at 3 month follow up. A static MILWAUKEE BRACE was used till year after surgery. Weaning of brace was done if XRAY reveals a mature fusion. Patients with a curve below T6 were given a TAYLOR’S BRACE while those with curves above T6 were given a MILWAUKEE Brace after surgery.

SURGERY HAARINGTON INSTRUMENTS



REVERSED HARRINGTON ROD TECHNIQUE



NEUROMUSCULAR SCOLIOSIS

S

No.

Age

(Yrs)

S

e

x

Compl

aint

Curve Pattern Angle Curve

Extent

Mode of Treatment Post

Op

Curve

Angle

Follow

up in

months

Follow

up

curve

angle

Early Late How

much?

1. 18 M D Right T 500 T3-

T11

A) Harrington

Instrument T2-

L2

B) Rib Hump

Excision 4

months after

(A)

47

60

4

1

47

60

NIL

Increase

in curve

NIL

NIL

Yes --

25%

In plaster

2. 10 F D Right TL 64.5 T-L Harrington Instrument

along with Sacral Bar

(T9-S

1)

46 5 46 NIL NIL Yes – 50%

3. 22 F B+D Right TL 53 T-L Harrington Instrument

along with bar ( T 9-S

1)

50 6 55 Dislodgm

ent of

lower

end of

rod

NIL No

4. 18 M D Right TL 48 T-L Harrington Instrument

along with sacral (T8-S

1)

35 5.5 38 NIL NIL Yes More

Than 90

5. 19 M B+D Left TL 55

T-L Posterior Spinal

Fusion (T10

–L5)

55 37 63 NIL Pseud

oarthr

osis

Yes

75%

6. * 11 F D Right CT 60 T-L Harrington Instrument

T1 – L

1

21

2 21 NIL NIL Yes

75%

7.* 33 M D Right TL 52 T-L Total Contact

Arthrosis

___ 2 50 NIL NIL Yes

8.* 23 F D+N Double

Right T

Curves

Left TL

98

87

T-T Undergoing

Preoperative traction

____ ____ ____ ______ _____

_

____

9.* 16 M D Right TL 40 T-L Milwaukee Brace ___ 8 38 NIL NIL Yes

10. 3 F D Left TL 32 T-L Total Contact

Orthrosis

____ 9 20 NIL NIL Yes

11. 18 M D Left TL 54 T-L T.C.O

12. 17 M D Right LTL 56 T-L Observation ___ 1 56 NIL NIL Yes



OUTCOMES

In this series, a total of 50 unselected patients of scoliosis of various etiologies have been studied. The various causes found in our series are tabulated as follows:-

AETIOLOGY

S.no

Aetiology No. of Patients Affected

Percentage of Total

I. Congenital 19 38%

II. Idiopathic 11 22%

III. Neuromuscular

A. Postpolio B. Others

12

8 4

24%

16% 8%

IV. Others

8

16%

Total

50

100%

The commonest single cause of scoliosis was congenital vertebral anomalies (amounting to 38%). Neuromuscular scoliosis and idiopathic scoliosis contribute 24% and 22% respectively to the series.

The commonest vertebral anomaly in our series was a result of the unilateral complete failure of formation of the vertebrae (in 47.3%)



CONGENITAL VERTEBRAL ANOMALIES

TYPES VERTEBRAL ANOMALIES Number of Patients

Percentage

1. Unclassifiable 3 15.78%

2. Fusion of Ribs 0

0 %

3. Unilateral failure of formation of Vertebrae: Partial(Wedge Vertebrae)

4

21.4%

4. Unilateral failure of formation of Vertebra: complete(Hemivertebrae)

9

47.3%

5. Bilateral failure of segmentation

0

0%

6. Unilateral failure of segmentation(unsegmented bars)

3

15.78%



TREATMENT

Number and Percentage of Patients in Groups

The total number of patients who received conservative treatment were 26, while rest of the twenty four were operated out of these 24, posterior

Spinal fusion was done in 14, Harrington instrumentation in 9 patients and Harrington instrumentation with posterior spinal fusion coupled with rib hump resection was done in one patients.

Mode of Treatment Congential Post Polio Neuromuscular Idiopathic Neuro

fibromatosis

Others

No. % No. % No. %

No. % No. % No. %

Conservative 9 47.4 3 37.5 3 75 7

57.5 1 33.3 4 80

Posterior Spinal fusion 10 56.6 1 12.5 - - - - 2 66.6 1 20

Posterior Spinal fusion

and Harrington

Instrument

- - 3 37.5 1 25 5 42.5 - - -

Excision of Rib Hump

with Instrumentation and

PSF

- - 1 12.5 -

- - - - - - -

Total 19 100 8 100 4

100 12 100 3 100 5 100



NEUROFIBROMATOSIS



SCOLIOSIS DUE TO NEUROFIBROMATOSIS



IDIOPATHIC SCOLIOSIS



POST POLIO



POST POLIO C-CURE



POST POLIO SCOLIOSIS



POST POLIO CURVE POST OPERATIVE



DISCUSSION

This series is based on 50 cases of Scoliosis that were studied at the Central Institution of Orthopaedics, Safdarjang Hospital, New Delhi, between April 84 to 85 of these 50 cases, 42 (i.e. 84%) were due to congenitial , idiopathic and neuromuscular Scoliosis . treatment for each of the patient was individualized . however, various types of treatment can be classified as under :

A. Conservative treatment including observation and postural exercises (26 cases)

B. Posterior spinal fusion (14 cases)

C. Harrington instrumentation augmented with Posterior spinal fusion (10

cases)

D. Later on rib hump resection was done in an Operated cases of paralytic scoliosis for Cosmetic reasons.

During the study maximum numbers of patients encountered were of congenital Scoliosis. These constituted 38% of the total cases, while idiopathic and neuromuscular scoliosis contributed 22% and 24% respectively to the series. These figures are markedly different from the western figures, which reveal that idiopathic scoliosis constitutes 75-80% of the Scoliosis patients in the west. This has been done to the virtual disappearance of poliomyelitis from the western hemisphere. Our results are similar to that obtained earlier by Dr. R.K.Gupta. During his work at C .I.O (1977) which revealed that 35.6% had congenital, 24.5% had paralytic and 28.9% had idiopathic Scoliosis .



CONGENITAL SCOLIOSIS

In this series, nineteen patients with congenital scoliosis were treated. Their age range was between 6 months to 18 years, the average being 10.4 years. In 13 out of the 19 patients, the age exceed 10 years of these 13 cases, 38.4% had curves. Between 20 to 40 while 61.6% had curves exceeding 40. In rest of 6 patients aged less than 10 years, 33.3% had curves between 20 – 40 while 66.6% had a curve exceeding 40. Our results resemble very closely to those of M.J.Mac Master et al (1984) who found that 64%of their patients of congenital Scoliosis about 10 years age had curves exceeding 40. Our series and M.J. Mc Master’s series reveal a poor prognosis for untreated cases of congenital scoliosis.



CONGENITAL SCOLIOSIS



SUMMARY

A series of fifty cases of scoliosis was studied at the central institute of orthopedics, Safdarjang Hospital, between April 1984 to March,1985. For these, following three main types of treatments were adopted :-

A. Observations and postural exercises (in 26 patients ) B. Posterior spinal fusion (in 14 cases) C. Harrington instrumentation augmented with posterior spinal fusion ( in 10

patients)

Beside these, a thoracoplasty for rib hump was done in a case of paralytic Scoliosis for cosmetic reasons. A follow up Study was done in two cases of scoliosis; those cases were operated upon about three years ago.

On the basis of the study following conclusions could be drawn:

1) The congenital, idiopathic and neuromuscular scoliosis together constituted 84% of the total cases and among these three, the Scoliosis arising from congenital vertebral anomalies accounted for the maximum number (38%) of the cases.

2) The average age of patients at the time of seeking medical advice was 14.8 years.

3) Males (56%) were affected more than the females (44%)

4) The usual curve pattern seen among the patients was - thoracolumbar which was been in 25 out of the 53 curves affecting 50 patients.

5) The range of curves in the patients varied from 19o to 98o, the average curve being 47%.



6) The average overall correction achieved by surgery was 23%.

7) The average correction achieved by posterior spinal fusion with post-operative

plaster was 2.6% while that achieved by Harrington Instrumentation was 30.7%.

8) Sacral bar was found to give satisfactory correction of the Paralytic pelvic

obliquity in two out of the three cases operated upon by this technique.

9) Major complications were found in four cases out of the twenty four cases, of

which two had instrument failure and two had peseudoarthrosis.

10) Application of inverted Harrington instrument for high cervicothoracic curves gave

excellent results.

11) Rib hump resection (thoracoplasty) done in a case of severe paralytic scoliosis

gave good cosmetic results.

12) The use of allogenic bone graft for posterior spinal fusion gave good results in

90% of all the cases so operated.

13) Follow up study done on two cases operated about three years ago revealed

solid fusion in one case and asymptomatic pseudarthrosis in other case.



CONCLUSIONS AND RECOMMENDATIONS

Early detection of scoliosis and early treatment is the cornerstone of success.

Observation and corrective exercises are important in resolving curves and

curves detected at less than 20o.

Early surgical invention in progressive curves with structural changes

and exceeding 50 degree.

Harrigton Instrumentation if combined with fusion gives more gratifying

results than fusion alone.

Allogeneic bone graft combined with autogenous graft can help where

autogenous graft insufficient.

Sacral rods were used in long C shaped thoracolumbar curves involving

the pelvis causing pelvic obliquity.

Rib hump resection should precede the correction of spine curvature.



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