George Sapkas1st Orthopaedic Department

Medical School – Athens University

University Hospital “ATTIKON”

Operative treatment of Idiopathic

Adolescent Scoliosis

Etiology Etiology

Idiopathic Idiopathic Neuromuscular Neuromuscular

– Cerebral palsyCerebral palsy– Muscular dystrophyMuscular dystrophy

Congenital Congenital Traumatic Traumatic Tumors Tumors etcetc..

(( Marfan syndrome)Marfan syndrome)Defecting gene Defecting gene

coding for f ibri l incoding for f ibri l in

• Fibrus dysplacia Fibrus dysplacia (bone collagen (bone collagen abnormality)abnormality)

• Muscle disorders Muscle disorders (Duchene musclear (Duchene musclear distrophy)distrophy)

• Soft t issue Soft t issue collagen disorder collagen disorder (Marfan syndrome)(Marfan syndrome)

Neuro f ibromatosis Neuro f ibromatosis

Spinal cord tumor Spinal cord tumor operated operated

Post laminectomy Post laminectomy instabil i ty instabil i ty

Scoliotic deformityScoliotic deformity

Arnold – Chiari syndromeArnold – Chiari syndromeSyringomyelia Syringomyelia

CongenitalCongenital

Tumor – Osteoid osteomaTumor – Osteoid osteoma

Idiopathic Adolescent Idiopathic Adolescent ScoliosisScoliosis

Etiology

Idiopathic Adolescent Scoliosis

1. Genetic factors2. Neurologic -//-3. Hormonic -//-4. Bio - engineering -//-5. Developmental - //-6. Chemical -//-• Melatonin• Calmodulin

7. Etc.

Is the labyrinthine dysfunction a causative Is the labyrinthine dysfunction a causative factor in idiopathic scoliosis?factor in idiopathic scoliosis?– Kapetanos G. et al, Kapetanos G. et al,

Stud Health Technol Inform 2002;91:7-9Stud Health Technol Inform 2002;91:7-9

No correlation was found between the convexity of the curvature and the direction of nystagmus in posture tests. There were no significant differences between left – and right – beating nystagmus.

Greek Research - Publications

a.

Idiopathic scoliosis: a transcranial magnetic Idiopathic scoliosis: a transcranial magnetic stimulation studystimulation study– Kapetanos G. et al,Kapetanos G. et al,

J. Musculo skelet Neuronal Interact 2007;155-60J. Musculo skelet Neuronal Interact 2007;155-60

The present TMS data do not support the concept of a generalized brain assymetry in IS. In lower limbs, a trend towards increased asymetries in side to side differences of CMCT and cortical latencies was detected probably representing subclnical involvement of the corticospinal tracts secondary to mechanical compression. Finally, it is concluded that non-decussation of the pyramidal tracts is not involved in the pathogenesis of IS

Greek Research - Publications

b.

Genetic factorsGenetic factors ((polygenic inheritance pattern)polygenic inheritance pattern)

MotherDaughter

Daughter Mother

The most common spinal curves

A B C D

Right thoracic Right thoracic apical vertebraapical vertebra 8 8 thth oror 9 9 thth

Thoracolumbar curveThoracolumbar curveApical vertebraApical vertebra 12 12 thth thoracicthoracic oror 1 1 stst lumbarlumbar

Lumbar curveLumbar curve apicalapical vertebravertebra 2 2 ndnd lumbarlumbar

Double curveDouble curveapical vertebraapical vertebra 8 8 thth thoracicthoracic andand 2 2 ndnd lumbarlumbar

King’s - Moe’s Classif ication

Spinal Curves

• Type I, primary lumbar curve greater than the compensatory thoracic curve;

• Type II, primary thoracic curve with compensatory lumbar curve;

• Type III, short pure thoracic curve;

• Type IV, long C-shaped thoracolumbar curve;

• Type V, double thoracic curve with extension into cervical spine and compensatory lumbar curve.

Lenke’s Lenke’s classif icatioclassif icatio

nn

Lenke’s Lenke’s classif icationclassif ication

Lenke’s Lenke’s classif icationclassif ication

Idiopathic Adolescent

Scoliosis

Treatment

Vertebral alignment – balance

disorganization

Treatment of curves Treatment of torsion

2D 3D

Risser signRisser sign

Vertebral ring apophysis

Type of Curve

Curve magnitude

(Risser sign )

Deterioration Deterioration vsvs

Chronological ageChronological age

Deterioration vs

biological maturity

Exercises

The effectiveness of exercises in individuals with idiopathic adolescent scoliosis has not been proved

Ebenbichler G. et al, 1994Universitat Klinik für

PhysikahischeMedizin und Rehabilitation,

Wien

Braces

MilwaukeeBostonStagnaraChennauMichelLyoneseetc

Idiopathic Idiopathic adolescent adolescent scoliosis scoliosis

< 40< 40 οο

Indications for bracingIndications for bracing

Deterioration of the curveDeterioration of the curve 1155οο 2200οο

Risser sign Risser sign 1 - 2 - 3 1 - 2 - 3

Maximum curve Maximum curve < 4< 400οο

Idiopathic Adolescent

Scoliosis

Operative treatment

Indications for Operative Indications for Operative TreatmentTreatment

Magnitude of the curveMagnitude of the curve> 40> 40oo – 45 – 45oo

Body deformityBody deformity Deterioration of the Deterioration of the

curvecurve Skeletal maturitySkeletal maturity Curve typeCurve type

Preoperative Preoperative evaluation evaluation

and and planningplanning

Stable vertebra

Dynamic bending x-raysDynamic bending x-rays

Dynamic bending x-raysDynamic bending x-rays

CT ScanCT Scan

MR-IMR-I

Past methods Past methods of of

operative treatmentoperative treatment

Harrington Harrington rod and rod and hookshooks

(distraction)(distraction)

Flat back

Dislodgment

Luque rods Luque rods and sublaminar wiresand sublaminar wires

(translation)(translation)

Hartshil l rod and interspinous wires Hartshil l rod and interspinous wires -Wisconsin technique--Wisconsin technique-

(translation)(translation)

Harrington rods and hooks Harrington rods and hooks – –

Luque rod and sublaminar wiresLuque rod and sublaminar wires(distraction – translation)(distraction – translation)

Flat back

Cotrell – Dubousset systemCotrell – Dubousset system(distraction - derotation)(distraction - derotation)

Rods - screws – hooks Rods - screws – hooks and sublaminar wiresand sublaminar wires

(distraction – translation – derotation)(distraction – translation – derotation)

Rods – screws and hooksRods – screws and hooks(derotation – distraction – translation)(derotation – distraction – translation)

Current Current operative techniquesoperative techniques

Neuro-monitoring Neuro-monitoring

Navigation systemNavigation system

Allografts

Anterior proceduresAnterior procedures

Anterior procedureAnterior procedure

Advantage : Limited number of included vertebra

Disadvantage : Orthopaedic surgeons are not familiar with the anterior procedure

Posterior proceduresPosterior procedures

Α. Μ.Α. Μ.F – F – 13+213+2TT55 – – TT99 ( (RR) 40) 40οο

TT1010 - - LL44 ( (LL) 50) 50οο King IKing I

Β. Β. PRPR..F – F – 1616TT66 - - TT1111 ( (RR) 70) 70οο

TT1212 - - LL44 ( (LL) 52) 52οο King IIKing II

Posterior procedures

Advantage : Orthopaedic surgeons are familiar with the posterior spinal procedures.

Disadvantage : Greater number of included vetrebra

Cases Cases

AA. . DD..F – 16+10F – 16+10TT66 - - TT1111 ( (RR) ) 2200οο

TT1212 - - LL44 ( (LL) ) 5050οο King IKing I

Ε. Ε. FRFR..F – F – 16+1016+10TT66 - - TT1111 ( (RR) 70) 70οο

TT1212 - - LL44 ( (LL) 52) 52οο King IIKing II

Χ. Β.Χ. Β.F – F – 1515TT66 - - TT1111 ( (RR) 62) 62οο

TT1212 - - LL44 ( (LL) 50) 50οο King IIKing II

ΜΜ... . SS..F – 21F – 21TT55 - - TT1111 ( (RR) 45) 45οο King IIIKing III

ΑΑNN. . SKSK..F – F – 3131TT66 - - TT1111 ( (RR) 43) 43οο

TT1212 - - LL44 ( (LL) 30) 30οο King IIIKing III

Ε. Β.Ε. Β.

F – F – 13+013+0 TT1100 – – LL33 ( (RR) 45) 45οο

King IVKing IV

Α. Α. KK..F – F – 1188++55TT55 – – TT99 ( (RR) 40) 40οο

TT1010 - - LL44 ( (LL) ) 4848οο King VKing V

Autografts

Double Spinal Deformity: a) Idiopathic adolescent scoliosis

b) Spondylolysis - spondylolisthesis

Post operative correction

Rib plasty

Complications Complications

FLAT BACK

Hook dislodgment Hook dislodgment

Idiopathic adolescent scoliosis operated 14 yrs agoHartshill system

Disc degeneration And arthritis below spondylodesia

Extension of spondylodesia

Dynesys dynamic system

Conclusions Conclusions Operative treatment of Operative treatment of

Idiopathic Adolescent Idiopathic Adolescent Scoliosis using the Scoliosis using the current trends of surgery current trends of surgery is able to provide: is able to provide:– Very satisfactory results Very satisfactory results

with great safetywith great safety

Conclusions Conclusions Comparing the Comparing the anterior anterior

vs the posteriorvs the posterior procedure there is an procedure there is an advantage of the anterior advantage of the anterior procedure related to the procedure related to the limited number of vertebra limited number of vertebra included in the included in the spondylodesia but the spondylodesia but the posterior procedures are posterior procedures are more familiar to more familiar to orthopaedic surgeonsorthopaedic surgeons

University Hospital “ATTIKON”