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Idiopathic Scoliosis Presented By Siti Nur Rifhan Kamaruddin

Idiopathic scoliosis

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Page 1: Idiopathic scoliosis

Idiopathic Scoliosis

Presented By Siti Nur Rifhan Kamaruddin

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OVERVIEW Definition: A spinal deformity characterized by lateralbending and fixed rotation of the spine in the absenceof any cause.

• This groups constitutes about 80% of all cases of scoliosis• In general, the younger the age at onset, the more likely the

deformity will progress and require treatment• The deformity is often familial• Age of onset : - Early Onset : Before puberty - Late Onset : After puberty

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ETIOLOGY

• Remains unknown• Several studies have suggested : - Genetic cause - Tissue deficiencies - Vertebral growth abnormalities - Central nervous system theories.

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CLASSIFICATION

• Based on Curve Location : Cervical Apex : C2-C6 Cervicothoraxic Apex : C7-T1Thoraxic Apex: T2-T12Thoracolumbar Apex : T12-L1Lumbar Apex : L2-L4

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Based on Age at Onset

Age of Onset : Infantile : Age birth to 3 years Juvenile : Age 4 to 10 yearsAdolescent : Age 11- 17 years(the most common)

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CLINICAL FEATURES • Pain : Not a common complaint • Discomfort can be a common feature but not

severe pain • Mild back discomfort and fatigue in 23% of

cases.• If severe pain : Must question etiology of the

idiopathic curve.

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Adolescent IDIOPATHIC SCOLIOSIS• Commonest type. Mostly in girls • Primary thoraxic curves are usually convex to the right ,

lumbar curves to the left. • Most curves < 20% : either resolve spontaneously or

remain unchanged • Once a curve start progress, it usually goes on doing

throughout growth period. • Progression predictors: - Very young age - Marked curvature - An incomplete Risser sign at presentation

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TREATMENT For Adolescent Idiopathic Scoliosis

Aim: To prevent progression To correct deformity

Based on : Skeletal maturity : Risser stage Curve magnitude : Cobb’s angle Curve progression : Observation

Treatment Options :The Three O’s

Observation Osthoses Operation

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• The Risser sign is an indirect measure of skeletal maturity, whereby the ossification stage of the Iliac apophysis is used to judge the ossification of the spinal vertebrae•The earlier the Risser Grade, the greater the likelihood of a scoliosis progressing to the point it becomes clinically significant and requires intervention.

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1.OBSERVATION

• The aim of observation for Adolescent idiopathic scoliosis is to identify and document the curve progression

• Curves less than 20° are observed.

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2. ORTHOTIC TREATMENT • Spinal orthotic is used to prevent curve

progression and generally, does not lead to permanent curve improvement.

• Although bracing is still being used, it is now recognized that it does not actually improve curve – at best, it just stops it from getting worse.

• Preference now : Wait for the curve to progress to the stage where corrective surgery would be justified.

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Contraindication for Brace treatment

• Skeletally mature patients

• Curves greater than 40°

• Thoracic lordosis ( Bracing potentiates

cardiopulmonary restriction)

• Patient unable to cope emotionally with

treatment

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Type of Brace• CTLSO ( Milwaukee Brace) : Consist of a pelvic corset connected

by adjustable steel supports to a cervical ring carrying occipital & chin pads.

• Used less commonly due to its cosmetic appearance.• Aim: Reduce lumbar lordosis & encourage stretching &

straightening of thoracic spine. • TLSO (i.e. Boston brace): Snug-fitting underarm brace. • Provide lumbar or lower thoracolumbar support.• Are better accepted by Pts. Indicated for curves with an apex T8

or below.• Bending brace (i.e. Charleston brace). It is worn only during sleep.

This type holds the Pt in an acutely bent position in a direction opposite to the curve apex.

• Flexible brace (i.e. SpinCor brace)

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Milwaukee Brace

Charleston BraceSpineCor Brace

Boston Brace

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3. OPERATION

• Objectives : To halt progression of the deformity To straighten the curveTo anthrodese the primary curve by bone grafting.

• Indications: Curves greater than 30° that are cosmetically

unacceptable esp. in prepubertal children Milder deformity that is deteriorating rapidly

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Operative/Surgery Options• The Harrington System

- The old, original system. - A rod was applied posteriorly

along the concave side of curve- attached to the rod were movable hooks that were engaged in the uppermost & lowermost vertebrae to distract the curve.

- Major Disadvantage: It does not correct the rotational deformity- rib prominence remains unchanged.

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• Rod and Sublaminar Wiring (Luque)- Modified Harrington

System- Wires are passed under

vertebral laminae at multiple levels and fixed to the rod at concave side of curve. – provides more controlled, secure fixation

- Disadvantage: Because the wires are dangerously close to the dura -> increase risk of neurological damage

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The Cotrel-Dubousset System- This method combines a pedicle

screw box foundation at the caudal end of deformity

- With multiple hooks placed at various levels to produce either distraction or compression.

- Using double rods can distract on the concave and compress on the convex side of the curve.

- Claimed that this method can correct rotational deformity as well.

- It is sufficiently rigid to make postoperative bracing unnecessary.

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Anterior instrumentation • This method approaches the

spine from the front.• It removes the discs

throughout the curve & then applying a compression device along convex side of curve.

• Bone grafts added to achieve fusion.

• Advantages- It provides strong fixation with less vertebral segment to be fused.

- Less risk of cord injury

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COMPLICATIONS OF SURGERY• Neurological compromise - With modern techniques, the incidence of permanent paralysis has been reduced to less <1%• Spinal Decompression - Over correction may produce an unbalanced spine. - This should be avoided by careful preoperative planning. • Implant Failure - Hooks may cut out and rods may break. If this is assoc. a symptomatic pseudarthrosis, revision surgery will be needed.

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EARLY ONSET IDIOPATHIC SCOLIOSIS(INFANTILE) (< 3 YEARS)

• Rare – Most babies nowadays are allowed to sleep prone • Male predominance• Left thoracic curve pattern is most common• 90% of infantile scoliosis resolves

spontaneously• Association with plagiocephaly,

developmental delay, CHD and DDH.

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Treatment for Infantile Id. Scoliosis• Due to the favorable natural history in 70% to 90% of patients with

infantile idiopathic scoliosis, active treatment often is not required. • Resolving curves - Most correct by 3 years age.

– observed with serial physical examinations and radiographic monitoring. (may recur in adolescence)

– Sleeping in the prone position is recommended

• Progressive curves are treated with serial casting followed by orthotic treatment with a Milwaukee brace

• The interval between cast changes is determined by the rate of the child’s growth, but a cast change usually is required every 2 to 3 months

• Surgery : posterior spinal instrumentation without fusion or the vertically expandable prosthetic titanium rib (VEPTR).

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A: Position on table with traction applied to halter and pelvis. B: Example of correction maneuver for de-rotation of left thoracic curve. C: Underarm cast with windows.

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EARLY ONSET IDIOPATHIC SCOLIOSIS(JUVENILE) (AGED 4-9 YEARS)• Less common than adolescent type.• Increasing female predominance• Most common curve patterns are

right thoracic. • Prognosis is worse : 70% of curves

progress and require treatment (surgery or bracing)

• If the child is very young, a brace may hold temporarily until Age 10, when fusion is likely to succeed.

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Treatment of Juvenile Id. Scoliosis• Juvenile idiopathic scoliosis is treated according to

guidelines similar to those for adolescent idiopathic scoliosis.

• Curve < 20°: Observation with examination and standing posteroanterior radiographs every 4-6 months.

• Evidence of progression on the radiographs as indicated by a change of at least 5 to 7 degrees warrants brace treatment. If the curve is not progressing, observation is continued until skeletal maturity.

• Curve 25° to 50° range : Orthotic treatment • Curve > 50° : Surgery

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REFERENCES

• Apley and Solomon’s Concise System of Orthopedics and Trauma 4th Edition. CRC Press