“twisted” crooked.

Dr KRISHNA M N

scoliosis

any lateral curvature of the spine > 10° in the coronal plane is called a scoliosis,

< 10° spinal asymmetry

2% to 4% in the general population

30% have family history

Idiopathic scoliosis(80%)

The common right (dextro) thoracic curve, measuring 10°, is generally considered physiologic and is thought to accommodate the size and position of the heart, lung, and aorta or to be related to handedness

Spontaneous resolution or improvement of curves < 10° can be observed in 3–20% of individuals, mostly boys.

The end vertebrae (E) are those most tilted,

the apex (A) is vertebra deviated farthest from the center of the vertebral column.

A neutral vertebra (N) is one that is not rotated,

a stable vertebra (S) is one that is bisected or nearly bisected by the CSVL (dotted line), which is exactly perpendicular to a tangent drawn across the iliac crests (solid line).

PRIMARY CURVE

First to developLargest curveStructuralNot correctable with

ipsilateral bendingvertebral

morphologic changes (eg, wedging and rotation)

May progressUsually >=25

Secondary curve

Compensatory curveSmaller curveNon structuralcorrectable with

ipsilateral bendingEnables sagittal and

coronal truncal balance

not usually progressUsually <=25

Primary curve Secondary curve

First to developLargest curveStructuralNot correctable with

ipsilateral bendingvertebral morphologic

changes (eg, wedging and rotation)

May progressUsually >=25

Compensatory curveSmaller curveNon structuralcorrectable with

ipsilateral bendingEnables sagittal and

coronal truncal balance

not usually progressUsually <=25

Nomenclatureand Measurement

Adams test

spinous processes deviate more and more to the concave side

rib hump in convex side

SCOLIOSIS CLASSIFICATION

PRIMARY AND SECONDARY

AGE-BASED: (idiopathic) infantile(birth and 3 years), juvenile (3 and 10 years of age), adolescent (10-25 skeletal maturity) MC

CAUSE,: Structural ( radio graphically Cobb angle of 25° or more on ipsilateral

side-bending radiographic views)

non-structural

LOCATION: apex vertebra

DIRECTION: concavity of the curve projects

CAUSAL CLASSIFICATION OF SCOLIOSIS

STRUCTURAL SCOLIOSIS(lateral curvature that is rigid and fails to correct on recumbent or lateral-bending) I. Idiopathic(80%) II . Congenital (10%) III. Neuromuscular IV. Neurofibromatosis V. Mesenchymal disorders VI. Rheumatoid disease VII. Trauma VIII. Extra spinal contractures IX. Osteochondrodystrophies X. Bone infection XI. Metabolic disorders XII. Related to lumbosacral joint XIII. Tumors

Non-structural scoliosis

I. PosturalII. HystericalIII. Nerve root irritation

A. Herniation of the nucleus pulposus B. Tumors

IV. Inflammatory (e.g., appendicitis)V. Related to leg length discrepancyVI. Related to contractures about the hip

IDIOPATHIC most common(80%) cause is unknown, Possible causes

connective tissue disease, diet, enzymes, muscular imbalance, vestibular dysfunction Inheritance up to 30% family history

< 2% levoscoliosis (F>M) 10 X > congenital heart disease than in the general

population when the idiopathic curve is> 20°.

HUETER-VOLKMAN PRINCIPLE

bone growth in the period of skeletal immaturity is retarded by mechanical compression on the growth plate and accelerated by growth plate tension

initiated by the rotation of vertebral bodies in the axial plane, which causes discrepant axial loading between the ventrally and dorsally located portions of the involved vertebrae

ventrally located part of the vertebral column becomes the concave side and the dorsally located part becomes the convex side of a lateral curve

AGE-BASED

Infantile(birth and 3 years), majority will disappear M>F (3.5:1) L>R Self limited (most of the time)

Juvenile (3 and 10 years of age), F>M (4:1) 30 % require surgery Thoracic type (t2-t11 apex vertebra)

Progression (70%–95% of patientsAdolescent (10-25 skeletal maturity) MC

F:M::9:1 right thoracic convexity screening of schoolchildren ceased spinal growth is indicated by fusion of the iliac

apophysis

CONGENITALassociated with vertebral anomalies

hemivertebrae, block vertebrae, spina bifida,, joint deformities, fusion of ribs,

C-SHAPED CURVE, short curve

rapidly progressive during GROWTH SPURTS

Frequent association of GENITOURINARY SYSTEM anomalies

VACTREL, Klippel–Feil syndrome

NEUROMUSCULAR

long C-shaped curvePoliomyelitis (MC)rapid progression in the curvature(12-16)15° or more occurring before the age of 11

should be viewed with a high index of suspicion for underlying intraspinal pathology..

Lt sided curves may show intraspinal pathology, syringomyelia, and Arnold-Chiari malformations,

are best evaluated with MRI

Cerebral palsy (2-limbs involved)

Myelodysplasia (lower lumbar)

Spinal muscle atrophy

Friedreich ataxia

Cerebral palsy (4-limbs involved)Duchenne muscular dystrophy

Myelodysplasia (thoracic level)

Traumatic paralysis (<10 years)

NEUROFIBROMATOSIS

The classic triad of diagnostic findings is multiple, soft, elevated cutaneous tumors (fibroma moll scum) cutaneous pigmentation (café-au-lait spots)

neurofibromas of peripheral nerves.

Scoliosis is the MC boney lesion in NFprogresses and requires surgical fusion for

stabilizationEnlarged foramina, posterior and lateral

vertebral body scalloping, deformed ribs (twisted).

foramina are greatly expanded from marked dural ectasia

TRAUMATIC SCOLIOSIS

Injuries to the spine that produce fracture or dislocation may also induce a lateral spinal curvature

, which may be permanent.comminuted “burst” fracture at T12,with loss

of vertebral body height, lateral wedging

Tuberculosisdeformity is a

sharp,angular kyphosis (gibbus),

vertebral collapse with the down sloping of the ribs owing to a gibbus deformity

the hypoplasia of the pedicle and lateral half of the vertebral bodies of L1–L4

RADIATIONgrowth arrest lines,

endplate irregularities, altered vertebral shape, and scoliosis

scoliosis caused by unilateral shortened lamina and pedicles.(radiation)

the convexity is away from the side of irradiation

Non-Structural

Corrected on recumbent lateral-bending

Leg length inequality ( fractures, epiphyseal

disorders, juvenile arthritis, and osteoarthritis) 43% are asymptomatic 75% with back ache Erect radiography single film of the hips, knees, and ankles Pelvic and sacral unleveling

RADIOLOGICAL FINDINGS Pelvic and sacral

unleveling Ispilateral scoliosis Compensatory scoliosis

Vertebral degenerative disc disease

Vertebral body wedging (L5 vertebra)

Femoral neck changes(primary compressive Trabeculae)

Assessment of scoliosis

the four basic spinal parameters evaluated in scoliosis are curvature, rotation, flexibility, skeletal maturation

CURVATURE MEASUREMENT

COBB- LIPPMANN :most acceptedAP radiograph entire spine(cervical sacrum).a line is drawn along the superior border of the

cephalad end vertebra and inferior surface of the caudad end vertebra

Perpendicular lines are erected from each endplate line, and the vertical (not horizontal) angle formed by their intersection is measured

Cobbs pitfall

diurnal variation of 5° prone positioning and anesthesia(rebound)difficult to position the patientintraobserver variation by 5°–10° in Cobb

angleDespite, increments of 5° in consecuitive

radiograph needs intervension

SEVEN GROUPS

0–20°21–30°31–50°51–75°76–100°101–125° ≥ 126°

the center of each end vertebra

the apical segment.These are then

joined, and their intersecting acute angle is measured.

Risser -Ferguson systems

ROTATION ASSESSMENT

AP radiographSpinous Method:position

of the spinous tip to the vertebral body

Pedicle Method (Nash-Moe method) most accepted technique The movement of the pedicle on

the convex side of the curve is graded between 0 and +4

Flexibility Assessment degree of mobility within a scoliosis correctability of a scoliosis risk for progression done bilaterally and with the patient supine bending toward the side of convexity as much as possible the degree of correction induced is the measure of

flexibility. In non-structural curves, the magnitude of the scoliosis

changes while structural curves remain unchanged

Skeletal Maturation

vital to determining treatment and prognosisLeft Hand and WristVertebral Ring EpiphysesIliac Epiphysis (Risser’s Sign).

Left Hand and Wrist

AP radiograph

< 20 years of age, Greulich and Pyle Atlas comparing

11 and 12 years- F>M

15 and 17 years- F<M

distal radial epiphysis closes at the same time as the vertebral body epiphysis

Vertebral Ring Epiphyses

traction epiphysesdo not contribute to vertical vertebral body

growthfusion to the body rim closely parallels the

maturation of spinal growth.most accurate indicator of completed spinal

growthstrong inhibiting factor to future scoliotic

progression.

ILIAC APOPHYSIS (RISSER’S SIGN).

first appears laterally near the A S I spine and progresses medially toward completion at the P S I spine (capping)

Boys -16yrs; Girls 14yrsGrade1 to 4 takes 1yr, grade 4-5 takes 2-3 yrsparallels the formation and progression of the

scoliosisgreatest rate of progression before appearancegrade 4 in F and grade 5 in M usually signals

the end of curve progression

13 yrs to 16yrs

grade 1, ≤ 25%grade 2, 26–50% grade 3, 51–75% grade 4, 75–100%grade 5,fused to the

ilium

Assessment of VertebralAlignment and Balance

The plumb: line is a vertical line drawn downward from the center of the C7 vertebral body, parallel to the lateral edges of the radiograph

CSVL :is a roughly vertical line that is drawn perpendicular to an imaginary tangential line drawn across the top of the iliac crests on radiographs. It bisects the sacrum.

CORONAL BALANCE is evaluated by measuring the distance between the CSVL and the plumb line

greater than 2 cm is abnormal

SAGITTAL BALANCE is evaluated by measuring the distance between the posterosuperior aspect of the S1 vertebral body and the plumb line

ADVANCED IMAGING TECHNIQUES

selective and judicious CT, and MRI is to identify a underlying causeguiding surgical treatment and evaluating

postoperative complications

Congenital osseous abnormality (fusion and segmentation anomaly)

Congenital neuropathic abnormality (Arnold- Chiari malformation, tethered cord, dysraphismrelated abnormality)

Dysplasia (neurofibromatosis, osteogenesis imperfecta, Marfan syndrome)

Pain suggestive of bone tumor, infection, or intervertebral disc herniation

Neurologic deterioration with abnormality at electroneurography or evoked electromyography

Preoperative evaluation of osseous abnormality Presumed postoperative complication

CLINICAL FEATURES Age <10 years Signs of neurologic deterioration Rapid progression Foot deformity Back pain, neck pain, headache

Radiographic features Curve type commonly associated with neuropathy

(left thoracic, double thoracic, triple major, short-segment, or long right thoracic curve; severe curvature after skeletal maturity)

Wide spinal canal, thin pedicle, wide neural foramina, or other features suggestive of a no osseous lesion

Computed Tomography

Optimum assessment of bony detailInvestigating back pain following

instrumentationwho are not able to undergo MRI

examination

RADIOLOGIC ASSESSMENT

Written Reports

patient’s right is on the right side of the interpreter

identification by name, age, institution, date, and file number

identify the projection, direction of bending erect or recumbent

the views performed, the patient position (whether erect or recumbent), Location of curves(C,CT,T,TL,L,LS,)Curve direction(Dx,Lv)End and apical vertebraeRotation assessment(PM)Curve magnitudeCauseSkeletal maturitySecondary complications

Lenke classification

Three Components:(a) curve type,

proximal thoracic (apex v T1 & T3), main thoracic (T3 &T12), Thoracolumbar to lumbar (T12 and L4).

(b) lumbar modifier, (A,B,C)

(c) thoracic sagittal modifier. (-, N, or +) T5 -T12

TREATMENT

dependent on the surgeon

Observation, bracing, and surgery are treatment options.

bracing has no role in adult idiopathic scoliosis (skeletally mature patients)

Surgery is the only option for congenital scoliosis

Surgery: achieving solid bone fusion of the involved vertebral segments, curve correction, trunk balance restoration, and sagittal contour preservation, while leaving as many mobile segments in the lumbosacral spine as possible

degenerative scoliosis, the goal is primarily spinal decompression

For idiopathic scoliosis, surgery is indicated in skeletally immature patients with a Cobb angle of 45° or more at presentation

Determining the Probability of Progression and the Appropriate Follow-up Interval

curve progression parallels spinal growth.

progresses only during growth

ceases when skeletal maturity is reached (final curvature is not severe)

< 50 degree Morbidity mortality equals with general

> 50 degree more Morbidity mortality (cardiopulmonary complications) After skeletal Maturity

The progression of idiopathic scoliosis afterskeletal maturity

less than 30°: tends not to progress

After the cessation of spinal growth, only curves with a Cobb angle greater than 30° will be monitored for progression

30°–50°:--- 10°–15° per year

50°–75°: ----1° per year

Congenital scoliosis progresses in 75% of cases

Idiopathic Infantile rarely progress

Idiopathic Juvenile progress 75-80%

Idiopathic adolescent progress only 5%

The factors that have the greatest effect on scoliosis are spinal growth velocity and magnitude of the curve at initial presentation

Observation idiopathic scoliosis less than 20 skeletally mature patient less than 30° Patients are followed up at 4- to 12-month

intervals

Bracing to avoid surgery 20°–45° in patients with adolescent idiopathic scoliosis progression of 5° or more occurs between consecutive

visits.

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