SCOLIOSIS

BY

SUBROTO SAPARDAN

POST GRADUATE COURSE FKUI 11-13 OCTOBER 2003

ETIOLOGY

I. GENETICS• TWIN STUDIES• FIRST DEGREE RELATIVES- 11 %

AFFECTED• SEARCH FOR RESPONSIBLE GENES

II. TISSUE DEFICIENCIES• BONE - OSTEOPENIA• MUSCLE - CALCIUM METABOLISM• LIGAMENT/DISC

ETIOLOGY

III. VERTEBRAL GROWTH ABNORMALITIES• PROGRESSION RELATED TO

GROWTH• FASTER ANTERIOR GROWTH –

HYPOKYPOSISS -ROTATIONAL BUCKLING OF SPINE

• AIS PATIENTS TALLER THAN PIERS• INCREASED GROWTH HORMONE

(PETERNEWTON SANDIEGO)

ETIOLOGY

IV. CNS THEORIES

• MANY NEUROMUSCULAR CONDITION

• SYRINX ASSOCIATED WITH SCOLIOSIS

• MELATONIN DEFICIENCY• PINEALECTOMIZED CHICKENS

PREVALENCE

• >300 CURVE: 1-3/1000, M : F = 1 : 8• CURVE PROGRESSION IN

ADULTHOOD– RARE IF < 30O

– COMMON IF• >50-750 THORACIC• >30-400 LUMBAR 1 /YEAR

• BACK PAIN HIGHER RATE THAN CONTROLS

PATIENT EVALUATION

• ADAMS FORWARD BENDING TEST

• LOOK-FEEL-MOVE

WALKING, STANDING (BACK, SIDE,

FRONT), FORWARD BENDING,

FLEXIBILITY, NEUROLOGICAL

EXAMINATION

IMAGING

• STANDING PA / STAGNARA VIEW

• LATERAL: SAGITTAL DEFORMITY

• BENDS FILMS– SIDE BENDING, FULCRUM BENDING

• MRI : – AGE < 10, LEFT THORACIC,

NEUROLOGICAL FINDINGS

NON OPERATIVE TREATMENT

I. OBSERVATION < 20-250 IMMATURE

II. ORTHOSIS CURVE > 20-250 < 40-500 IMMATURE, RISSER < 3

BOSTON TYPE/MILWAUKEE

III. EXERCISE :

NO EVIDENCE TO SUPPORT THIS ALONE

BENEFICIAL IN BRACED PATIENTS

AIS : CURVE CLASSIFIKATION

LOCATION OF APEX

CERVICO-THORACAL : C7-T1/2 DISC

THORACIC : T2 – T11/12 DISC

THORACO-LUMBAR : T12-L1

LUMBAR : L1/2 DISC- L4

LUMBOSACRAL : L5-S1

LENKE, BETZ, HARMS JBJS 2001

CURVE PT MT TL.L CURVE TYPE

1 NS S NS MAIN THORACIC (MT)

2 S S NS DOUBLE THORACIC (DT)

3 NS S S DOUBLE MAJOR (DM)

4 S S S TRIPLE MAJOR (TM)

5 NS NS S TL/L

6 NS S S TL/L-MAIN THORACIC

CURVE TYPES (1-6)

LUMBAR CURVE MODIFIER :• POSITION OF CENTER SACRAL VERTICAL

LINE (CSVL) TO APEX OF LUMBAR CURVE

SAGITTAL THORACIC MODIFIER :• T5-T12 SAGITTAL COBB - : <100

N : 10 – 400

+ : > 400

CURVE CLASSIFICATION

CURVE TYPE (1-6)

+

LUMBAR CURVE MODIFIER (A,B OR C)

+

SAGITTAL THORACIC MODIFIER(-,N,+)

CURVE CLASS : 1A-,1AN, 6CN, 6C+

LENKE

• TYPE I : MT - PSSI OR ASSI

• TYPE II : DT- PSSI- PT + MT

• TYPE III : DMC – PSSI- MT+TL/L

MT ONLY < 600

MT RIGID

INFORMED CONSENT

SAFE L4 STOP AT L3

LENKE

• TYPE IV : TMC – PSSI – PT, MT,TL/L

• TYPE V : TL/L – ASSI TL/L ALONE

• TYPE VI : TL/L + MT

PSSI MT + TL/L

METHODS

METHODS

METHODS

METHODS

THE 6,35 MM STAINLESS STEEL ROD IS PREBENDED IN KYPHOSIS IN THE THORACIC SPINE AND LORDOSIS IN THE LUMBAR SPINE

METHODS

THE ROD IS PLACED IN 450 TO 60 TOWARDS THE CONCAVE SIDE FROM THE MIDSAGITTAL PLANE

METHODS

DISTRACTION WITH THE SPREADER UNTIL THE HOOKS ARE LOCKED IN PLACE WITH THE ANTI ROTATION SYSTEM

METHODS

THE SUBLAMINAR WIRES ARE TIGHTENED ONE BY ONE GRADUALLY UNTIL THE CURVE CORRECTED BY PERIAPICAL TRANSLATION FOLLOWING THE LEEDS METHOD AND THE SCOLIOSIS IS CONVERTEDINTO NORMAL KYPHOSIS

METHODS

METHODS

THE CORRECTED DEFORMITY IS NEUTRALIZED / STABILIZED USING THE SPINAL RECONSTRUCTION PLATE WITH SEGMENTAL PEDICLE SCREWS

METHODS

IN KING TYPE 1 CURVES AND LENKE TYPE 5 AND 6 THE ROD HAS TO BE CONTOURED AS AN “ S ” SHAPED BOTH IN THE SAGITTAL AND CORONAL PLANE WITH THE RECONSTRUCTION PLATE

AND FORMS A CROSSED INSTR.

METHODS

THIS INSTRUMENTATION IS NAMED THE UI SYSTEM AFTER UNIVERSITY OF INDONESIA WITH PATENT PENDING NO. P 00200200388

PATIENTS

FEB. 1998 – NOV. 2000

54 AIS MEAN AGE 17,5 YEARS

MEAN CURVE SEVERITY 72,2 DEGREES

MEAN CORRECTION 68,6%

FEB 1998 – DEC 2002

94 PTS

RESULTS FOLLOW UP 2 YEARS

MEAN CORRECTION 68,6%

ALL COMPENSATED

NO HYPOKYPHOSIS

PATIENT’S / PARENT’S

SATISFACTION 85/100

COMPLICATIONS

INSTRUMENTATION FAILURE Θ

2 DEEP LATE INFECTION

→ REMOVAL OF INSTR.

F, 14 y o, Lenke 1 A - T5-T11 110/87 58

T5-T11 110/87 58

F, 31 y o, Lenke 1 A- T4 – T12 84/72 42

T4 – T12 84/72 42

F, 12 y 0 Lenke 3 C n T4 – T11R 80/61 30 T11 L4 L 66/35 21

Crossed UI system

F 14, Lenke 5 C+, T11-L3 135/105 58

Kyphosis 90 36, Rotational hump 6 1,5

T11-L3 135/105 58

T11-L3 135/105 58

CONCLUSIONS : THE UI SCOLIOSIS SYSTEM

* GOOD 3 DIMENSIONAL CORRECTION

* STABLE INSTRUMENTATION (NO EXTERNAL SUPPORT REQUIRED)

* INEXPENSIVE

OFFERS GOOD – EXCELLENT COSMESIS IN A BALANCED SPINE