SPINE DEFORMITY

By:

Supervisor: dr. Karya Triko Biakto, Sp.OT (K) Spine

OrTHopedic dan TraumatologyFaculty of Medicine Hasanuddin universityMakassar 2015

SPINE DEFORMITYANATOMY

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders.

ANATOMY1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders.

ANATOMY

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders.

ARTERIES OF SPINE

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders.

5Vein of Spine

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders.

Balance curves of the normal spine

Feeman B. Scoliosis and Kyphosis. In: Canale Terry S. Campbells Operative Orthopaedics. 10th Edition. Volume One. Philadelphia: Elsevier. 2003.

SPINAL DEFORMITIESReality: Spinal deformities are complex and simultaneously afect the sagittal, coronal, axial plane3. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics and Fractures. Ninth Edition. UK: Hodder Arnold. 2010. p. 453-70.

KYPHOSIS- Normal spine profile of the thoracic region of the spinal column- Normal range of thoracic kyphosis: 20-50 degrees (Cobb angle from T3 to T12)

Greater than 50 degrees: HYPERKYPHOTIC3. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics and Fractures. Ninth Edition. UK: Hodder Arnold. 2010. p. 453-70.

Causes of Kyphotic

4. Devlin Vincent. Spine Secret Plus. Second Edition. Missouri: Elsevier mosby. 2012. P. 10-7, 34-45, 52-8

A tall teenager with postural thoracic hyperkyphosis and lumbar hyperlordotic3ClassificationClassificationScheuermanns DiseaseThe cause is probably multifactorialScheuermann: avascular necrosis necrosis of the ring apophysis of the vertebral body.Bick and Copel: disturbance in the ring apophysis should not affect growth of the vertebra or cause vertebral wedging.Aufdermaur and Spycher suggested that a biochemical abnormality of the collagen and matrix of the vertebral endplate cartilage may be important in the etiologyEtiologyClinical FindingsStarts at pubertyAffects boy more than girlsBackache and fatigue, sometime increase after the end of growth and may become severeMarked humpMovements are normal but tight hamstring often limit straight leg raising.

Figure 6. A young girl with marked exaggregation of the usual thoracic kyphosis. X-ray examination show the typical indentations in the vertebral end plates and wedging of vertebral bodies.3Physical ExaminationAngular thoracic or thoracolumbar kyphosis with compensatory hyperlordosis of lumbar spineSharply angular and doesnt correct with the prone extension testThe lumbar lordosis below the kyphosis usually is flexible and corrects with forward bending.Apparent when viewing the patient from the side, and the deformity is increased on the Adam forward bend test Physical Examination

Adam forward bend test. Angulated spine profile seen in patient with Scheuermanns diseaseRadiological FindingsThe criteria for the diagnosis : more than 5 degrees of wedging of at least three adjacent vertebrae at the apex of the kyphosis and vertebral endplate irregularities with a thoracic kyphosis of more than 45 degrees. Radiological FindingsOn a lateral view made with patient standing, the degree of wedging is measured by drawing a line along the superior and inferior endplates of each vertebral body and measuring the angle of intersectionThere may also be small radioluscent defects in the subchondral bone (Schmorls node), which are thought to be due to central (axial) disc protrusions.Radiological Findings

Lumbar Scheuermanns diseaseSchmorls nodeTreatmentTreatment

Operative correction and fixation with Wisconsin rods, bone grafts were added and can be expected to produce fusion after a year or two3SequeleBackache Embarrassment about physical appearanceInterruption of work or disabilitySevere progressive deformityCardiopulmonary failureSpondylysthesisDisc degenerationDifferential DiagnosisPostural round back deformitiesSpondylitisOsteochondrodystrophiesAnkylosing spondylitis SCOLIOSISDefinitionScoliosis is an apparent lateral (sideways) curvature of the spine

The commonest form is triplanar deformity : lateral, anteroposteriorand rotational components.

Two types of deformity : postural and structural

Postural Scoliosis

(a) This young girl presented with thoracolumbar curvature. When she bends forwards, the deformity disappears; this is typical of a postural or mobile scoliosis. (b) Short-leg scoliosis disappears when the patient sits. (c) Sciatic scoliosis disappears when the prolapsed disc settles down or is removedStructural Scoliosis

Figure (a) Slight curves are often missed on casual inspection but the deformity becomes apparent when the spine is flexed (b). The young girl in (c) has a much more obvious scoliosis and asymmetry of the hip but what really worries her is the prominent rib hump, seen best when she bends over(d).

EpidemiologyThe incidence is approximately 1% in the general populationChildren of women with scoliosis > (particularly in the daughters of these women)The most common type is idiopathic scoliosisScoliosis may occur at any age.The most common age at diagnosis of idiopathic scoliosis is 11-13 years.

Etiology (classification by its cause)

Clinical FindingDeformity : an obvious skew back or a rib hump in thoracic curves, and asymmetrical prominence of one hip in thoracolumbar curves

Pain is a rare complaint (alert the clinician to the possibility of a neural tumour)Physical examinationThe history should include :the age when the deformity was first noted; the manner in which it was noted; the perinatal history; developmental milestones; other illnesses; and family history of scoliosis or other diseases that may affect the musculoskeletal systemInspectionThe trunk should be completely exposed , examined from in front, from the back and from the side.Inspect the skin over the entire spine for dimples, hair, or vascular markings, which may signal an underlying congenital anomaly.Examine the patient, while he or she is standing, to see shoulder, rib, and hip asymmetry.In patients with scoliosis, the shoulders or pelvis may not be level, or waist asymmetry may be noted. Most commonly, these patients have scapular prominence, with rotational deformity and rib prominence.Asked the patient to bend forward at the waist until the shoulders and hips are in the same axial plane

The rotational deformity of scoliosis is manifested by a rib hump, which is accentuated by having the patient bend forward36Measurement of decompensation by dropping a plumb bobfrom the prominence of the C7 spinous process and measuring where it falls with respect to the gluteal line.

Neurologic TestsDemonstrate a normal gait and be able to walk on their toes and heelsMotor and sensory testing of the lower extremities should be performed, and testing of the upper extremities should also be done if neuromuscular condition is suspected. Reflexes should be tested, and the presence of asymmetry or a pathologic reflex suggest a non idiopathic etiology.

IMAGING STUDIESX-RayIn younger patients, special attention is paid to the pelvis on the P/A x-ray to assess skeletal maturity by Risser Classification

Risser grade 1 patients have ossified only 25% of their iliac apophysis. Risser grade 4 patients have ossified 100% of their iliac apophysis, but have not fused their iliac wing to their ileum. Risser grade 5 patients are skeletally mature and have ossified their entire iliac apophysis and fused their iliac wing to the ileum

Curvature Measurement

Measurement of the Cobb angle. End vertebrae are the last levels that are tilted into the curve concavity. A line is drawn from the superior endplate of the superior end vertebral body, and another line is drawn from the inferior endplate of the inferior vertebral body The angle of the intersection of these lines is the Cobb angle.

the results of multiple studies done to assist in predicting the risk of curve progression in adolescentsPROGNOSIS AND TREATMENTPrognosis is the key to treatment. The aim is to prevent severe deformity. Generally speaking, the younger the child and the higher the curve the worse is the prognosis.

Management differs for the different types of scoliosis, which are consider laterIDIOPATHIC SCOLIOSIS

Infantile Idiophatic ScoliosisInfantile idiopathic scoliosis is a structural, lateral curvature of the spine occurring in patients younger than 3 years of age

More frequent in boys than in girls, and were primarily thoracic and convex to the leftEtiology and Clinical FindingEtiological factors of infantile idiopathic scoliosis are multiple, with a genetic tendency that is either triggered or prevented by external factors

Mental retardation in 13%, inguinal hernias in 7.4% of boys with progressive scoliosis,congenital dislocation of the hip in 3.5%, and congenital heart disease in 2.5% of all patients

A girl age 2 years + 9 months who presented with severe infantile onset idiopathic scoliosis

Treatment(1) serial casting, progressing to bracing and later fusion, (2) preoperative traction to correct the curve followed by fusion, and (3) subcutaneous instrumentation without fusion. Juvenil Idiophatic ScoliosisJuvenile idiopathic scoliosis appears between the ages of 4 and 10 years.

The characteristics of this group are similar to those of the adolescent group.

Convexity of the thoracic curve usually is to the right. TREATMENTFor curves of less than 20 degrees, bservation is indicated, with examination and standing posteroanterior roentgenograms every 4 to 6 monthsAdolescent Idiophatic ScoliosisThe characteristics of adolescent idiopathic scoliosis : a three-dimensional deformity of the spine with lateral curvature plus rotation of the vertebral bodies.Etiology

Possible interrelationships of various factors that have been shown to have possible role in cause of idiopathic scoliosisTREATMENTNON OPERATIVEIf the patient is approaching skeletal maturity and the deformity is acceptable (which usually means it is less than 30 degrees and well balanced), treatment is probably unnecessary unless sequential x-rays show definite progression.Bracing has been used for many years in the treatment of progressive scoliotic curves between 20 and 30 degreesOperative TreatmentSurgery is indicated: (1) for curves of more than 30 degrees that are cosmetically unacceptable, especially in pre-pubertal children who are liable to develop marked progression during the growth spurt; (2) for milder deformity that is deteriorating rapidly. CONGENITAL ANOMALIESCongenital scoliosis is a lateral curvature of the spine caused by the presence of vertebral anomalies that result in an imbalance of the longitudinal growth of the spine

The cause of congenital vertebral anomalies remains unknown. During embryologic development, these abnormalities develop in the spine between the fifth and eighth weeks of gestation, but it is very uncommon to identify any traumatic or teratologic type of maternal insult during this stage of pregnancy. CLASSIFICATION

Physical ExaminationThe skin of the back should be carefully examined for signs such as hair patches, lipomata, dimples, and scars, which may indicate an underlying anomalous vertebra

The neurological evaluation should be very thorough

Hair patch associated with diastematomyelia and congenital scoliosisTREATMENTTreatment is more difficult and specialized than that of idiopathic infantile scoliosis. Progressive deformities (usually involving rigid curves) will not respond to bracing alone, and surgical correction carries a significant risk of cord injury.These children should be treated in special units: the approach is to undertake staged resection of the curve apex, followed by instrumentation and spinal fusion. If multiple segments of the spine are involved, surgery may be too hazardous and should probably be withheld.3

NEUROMUSCULAR SCOLIOSISNeuromuscular conditions frequently associated with scoliosis include muscular dystrophy, cerebral palsy, poliomyelitis, spinal cord tumor, spinal cord trauma, spinal muscular atrophy, Friedreich ataxia, syringomyelia, familial dysautonomia, and myelomeningocele ETIOLOGY

CLINICAL FINDINGSpinal deformities tend to present early in life in patients with these conditions and often progress to severe deformities because of muscle weakness and the many years of ensuing growth. The assessment of patients should be detailed and include an evaluation of overall function, mental status, motor strength, ambulatory status, and sitting tolerance as well as a search for the presence of problems such as joint contractures, pelvic obliquity, and pressure sores. Joint contractures can lead to pelvic obliquity or can limit the patient's ambulatory or sitting ability.

Pelvic obliquity or a dislocated hip can be primary and lead to scoliosis or can be secondary to the spinal deformity. The primary condition should be determined, and if corrected sufficiently early, may obviate or delay the need for further corrective surgery.8

TREATMENTTreatment depends upon the degree of functional disability. Mild curves may require no treatment at all. Moderate curves with spinal stability are managed as for idiopathic scoliosis. Severe curves, associated with pelvic obliquity and loss of sitting balance, can often be managed by fitting a suitable sitting support. If this does not suffice, operative treatment may be indicated. This involves stabilization of the entire paralyzed segment by combined anterior and posterior instrumentation and fusion.

REFERENCEThompson JC. Netters Concise Orthopaedic Anatomy. Second Edition. Philadelphia: Elsevier Saunders. p. 31, 65-6Feeman B. Scoliosis and Kyphosis. In: Canale Terry S. Campbells Operative Orthopaedics. 10th Edition. Volume One. Philadelphia: Elsevier. 2003. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics and Fractures. Ninth Edition. UK: Hodder Arnold. 2010. p. 453-70.Devlin Vincent. Spine Secret Plus. Second Edition. Missouri: Elsevier mosby. 2012. P. 10-7, 34-45, 52-8Mummaneni P, Ondra LS, Sasso CR. Thoracolumbar Deformity Advances. In: Haid WR, Subach RB, Rodts EG. Advances in Spinal Stabilization. Volume 16. Karger. 2003. P.213-24.Schiller J, Craig, Eberson. Spinal Deformity and Athletics. Sports Med Arthrosc. Volume 16, Number 1. March 2008.Salter B Robert. Textbook of Disorders and Injuries of the Musculoskeletal System. Third Edition. Lippincott Williams and Wilkins. 1999. Skinner HB, Agudelo JF. Current Diagnosis and Treatment in Orthopaedics. 4th Edition. USA: The McGraw-Hill Companies. 2006.Canale, terry. Campbell's Operative Orthopaedics, 10th ed. Congenital Scoliosis. Elsevier London:2007. Anthony B.Congenital Scoliosis. Tachdjians Pediatric Orthopaedics.Philadelphia; 2008Frassica F. Scoliosis.5-Minute Orthopaedic Consult, 2nd Edition. Lippincott Williams & Wilkins: 2007.p.372-5Haid RW. Thoracolumbar Deformity Advances.Advance in Spinal Stabilization.USA: Karger; 2003.p.213-20Slakey J. Adolescent Idiopathic Scoliosis: Review and Current Concepts. American Family Physician www.aafp.org/afp.