SPINAL DEFORMITIE’S

BY ,

NEHA GAGGAR (MPT)

SPINAL DEFORMITYDEFINTION : any abnormality of the formation , alignment , or shape of the vertebral column .TYPES :1. Frontal plane

scoliosis 2. Sagital plane

forward head kyphosis exaggerated lordosis flat back

However SCOLIOSIS have multiplanar component : frontal sagital torsional

SCOLIOSIS

DEFINITION :Appreciable lateral deviation (>10 degrees) in the normally straight vertical line of spine.

ETIOLOGY :GeneticDisorders of bone , muscle, discDevelopmental growth abnormalitiesCentral nervous system causes

CLASSIFICATION

SCOLIOSIS

C

STRUCTURAL NONSTRUCTURAL

A.Idiopathic A.Postural Infantile(0-3yrs)

B.Compensatory juvenile (4-9yrs) C.Sciatic Adolescent (10-20 yrs)

B.CongenitalC.Neuromuscular

GRADES OF SCOLIOSIS

Grade I mild postural scoliosis

Grade II structural scoliosis with curve < 40 degrees

Grade III structural scoliosis with curve > 40 degrees

CURVE PATTERNS

1.Cervical curve : apex between C1 – C62.Cervicothoracic curve : apex is at C7, T1

3.Single major thoracic curve : Apex is between T2 – T11 4.Single major high thoracic curve : Apex from T3 with the curve extending from C7 or T1 to T4 or T5 5.Single major lumbar curve: Apex between L1-L2 and L4 6.Single major thoracolumbar curve : Apex is at T12 or L1 7.Combined thoracic & lumbar curves (double major curves) : Symmetrical double major curves 8.Double major thoracic curve : Upper thoracic from T1 to T5 or T6 and convex to the left

SCOLIOTIC CURVES

1. Compensatory curve due to primary curve

2. Compensatory curve due to deformities in other parts of the body

3. Rotational element

EVALUATION

I. INSPECTIONA.OBSERVATION

1.level of ear & contour of neck2. shoulder level3. scapular level4. position of the arms and the waist line5. back6. thorax

concave : ribs crowded & flattenedconvex : ribs apart & buldge backwards

7. hips & PSIS8. pelvis : concave : forward rotation9.knee10.feet

EVALUATION CNTD...

B. ADAMS TEST

II. EXAMINATION 1. Range of motion 2.scoliometer

EVALUATION CNTD...

3.Cobb angle measurement : The Cobb method is used to measure the degree of scoliosis

on the posteroanterior radiograph .

STEP 1 : the apical vertebra is first identified; this is the most likely displaced and rotated vertebra with the least tilted end plate.

STEP 2 : The end/transitional vertebra are then identified through the curve above and below. The end vertebra are the most superior and inferior vertebra which are least displaced and rotated and have the maximally tilted end plate. 

STEP 3 : A line is drawn along the superior end plate of the superior end vertebra and a second line drawn along the inferior end plate of the inferior end vertebra.The angle between these two lines (or lines drawn perpendicular to them) is measured as the Cobb angle.

EVALUATION CNTD...

4. To check vertebral rotation : Nash and moe method, Look at the pedicles If they are equidistant from the sides of the vertebral bodies ,

no vertebral rotation (0 rotation) Grade 4 is in which the pedicle is past the center of the

vertebral body.

5. Skin marker

EVALUATION CNTD...

6.Rib Mehta’s angle(Difference at the apical rib) is of prognostic value.The RVA difference (RVAD) is the difference between the values of the RVAs on the concave and convex sides of the curve [apical vertebra]. If the convex apical rib head does not overlap the apical vertebral body, a curve with an initial RVAD of 20º or more is considered progressive.One line perpendicular to the apical vertebral endplate and another from the mid neck to the mid head of the corresponding rib.

7.MRI8.CT Myelography

MANAGEMENT

OBSERVATION

SURGERY

BRACING

PREVENTIVE ROLE

early detection

screening programme for all school children of age between 10-14 yrs

education of parents and teaching them simple observational technique

BASIC PRINCIPLES OF CORRECTION

1. ACTIVE CORRECTION :self corrective postural activities

2. PASSIVE CORRECTION :Unequal hangingAxial traction given by 2 therapists

3. MAINTENANCE OF CORRECTION :Education of patientSpinal bracing

MANAGEMENT FOR GRADE I

Re-education of bad posture monitoring after every 6 months regimen includes:

general body relaxation re-education of correct posture passive correction repeated session of maintenance of corrected posture general free mobility exercises strengthening – spinal extensors, abdominals deep breathing ex balance ex stretching of concave side avoiding activities prone to produce the deformity

MANAGEMENT FOR GRADE II

MILWAUKEE BRACEAka Cervicothoraciclumbosacral orthotic (CTLSO brace)

•Adjustable ht, can ‘grow’ with the patient•Worn 23 hrs/day•Contains pelvic attachment, thoracic pads, and chin support•Primary goal = stop progression of scoliosis•Very effective if treatment plan is followed

BOSTON BRACEAka ‘Low Profile’ Thoracolumbarsacral orthotic (TLSO)

•Primarily used for lower thoracic, thoracolumbar , & lumbar curves

•Still widely used, due to better patient acceptance than Milwaukee Brace

EXERCISE THERAPY

Goals = Improve ROM• Especially in direction of convexity• Reduce contractural change of soft tissues

on concave side

Done through:• Improve strength, endurance, & postural

control of muscles on convex side• Identify & correct vestibular and/or

proprioceptive imbalance/deficiency• Improve balance & coordination• Normalize weight bearing in lower

extremities & spine

Specific Exercises:• Stretch concave side = balance ball, hanging

from bar, leaning against wall

• Strengthen convex side = active exercise

• Strengthen trunk muscles

• Rotary torso exercises to left (right thoracic curve)

• Proprioceptive training

• Heel lift (up to 5 mm) – goal is to balance weight bearing for CNS re-education, re-evaluate every 6 weeks

•Exercises to restore cervical lordosis•Work with Exercise Ball – proprioceptive control•Sleep posture – lying on side with pillow under ribs

•To correct pelvic unleveling (ex. elevated Rt. Ilium)

• Strengthen: Lt. QL, Lt. hip adductors, Rt. G Med

• Stretch: Rt. QL, Rt. hip adductors, Lt. G Med

•Breathing exercises – maximize & normalize chest expansion

MANAGEMENT FOR GRADE III

Surgery is the treatment of choice TRACTION

NONSKELETAL SKELETAL

1.Combination of intermittent and continuous 2. Superimposition of both3. Traction of gravitational

1.Halopelvic2. halofemoral

INDICATIONS FOR SURGERY

1. Cord compression

2. Rapid progressive curve

3. Severe pain4. Respiratory impairment5. Cosmetic

AIMS OF SURGERY

1. Restore the symmetry of trunk as much as possible 2. Straighten the thoracic curve to stop decrease in

pulmonary function

PRINCIPLES OF SURGERY

I . CORRECTION OF CURVE : 1. turnbuckle cast techniques 2. distraction technique3. lessening of the curve

II. MAINTENANCE OF CORRECTION ACHIEVED 1. spinal fusion 2. spinal instrumentation

harringtons instrumentation segmental spinal instrumentation Dwyers instrumentation Zieko instrumentation

PREOPERATIVE PHYSIOTHERAPY

measurements assessment of pulmonary function muscle charting detailed neurological examination gait analysis and functional status postural guidance spinal stretching and mobility

POSTOPERATIVE PHYSIOTHERAPYFIRST 2 DAYS Respiratory status Ankle toe movements upper extremity mobilityPassive movts to lower limb turning every 2 hrly

3 RD & 4 TH DAY Active movts for lower limb measurement of curve

AFTER 5 DAYS Guidance in rolling , sitting , standing sitting chair sitting standing and walking

THANK YOU....