IDIOPATHIC SCOLIOSIS

• Scoliosis is an apparent lateral (sideways) curvature of the spine.

• ‘Apparent’ because, although lateral curvature does occur actually a triplanar deformity with lateral, anteroposterior and rotational components (Dickson et al., 1984).

General classification

• Postural scoliosis– the deformity is secondary or compensatory to some

condition outside the spine, such as a short leg, or pelvic tilt due to contracture of the hip.

• Structural scoliosis– Structural scoliosis there is a non-correctable deformity of

the affected spinal segment,

Etiology

• Congenital scoliosis• Idiopathic scoliosis• Neuromuscular scoliosis

IDIOPATHIC SCOLIOSIS

• Idiopathic scoliosis is the most common type of scoliosis.

• defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine in the absence of any known cause

• In general, the younger the age at diagnosis, the more likely the deformity will progress and require treatment.

A lateral deviation and rotation deformity of the spine without an identifiable cause.

Divided in to 3 sub groups based on the age onset :1.Infantile idiopathic scoliosis ( birth to 3 years old )2.Juvenile idiopathic scoliosis ( 4 to 10 years old )3.Adolescent idiopathic scoliosis ( after 10 years old ) the most common

infantile idiopathic scoliosis

• Common in Europe but rare in the United States (1% of cases in United States)

• Male predominance

• Left thoracic curve pattern is most common (vs. adolescent idiopathic scoliosis, in which right-sided thoracic curves are typical)

• Association with plagiocephaly, developmental delay, congenital heart disease, and developmental hip dysplasia

• Two types have been identified: a resolving type (85%) and a progressive type (15%)

• distinguished by analyzing the rib-vertebral angle difference (RVAD) and rib phase

Progressive type– RVAD convex – concaf >20° – Rib phase 2

Treatment forinfantile idiopathic scoliosis

• Resolving curves – observed with serial physical examinations and radiographic

monitoring. – Sleeping in the prone position is recommended

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

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

• Posterior spinal instrumentation and fusion are not recommended due to: – restriction of thoracic cage and lung development, – the risk of crankshaft phenomenon (persistent anterior spinal growth in the presence of a posterior fusion, leading

to recurrent and increasing spinal deformity).

• In extreme cases, a combined anterior and posterior fusion procedure is an option but will limit development of the thorax, lungs, and normal trunk height.

juvenile idiopathic scoliosis

• Less common than adolescent idiopathic scoliosis (12%–16% of all patients with idiopathic scoliosis)

• Increasing female predominance is noted with increasing age (female-to-male ratio is 1:1 from 4–6 years and increases to 8–10:1 from 6–10 years)

• Most common curve patterns are right thoracic

• Approximately 70% of curves progress and require some forms of treatment (bracing or surgery)

• Magnetic resonance imaging (MRI) of the entire spine (also in infantile idiopathic scoliosis) because spinal deformity may be the only clue to the presence of a coexistent neural axis abnormality

Treatment of juvenile idiopathic scoliosis

• Orthotic treatment is initiated for curves in the 25° to 50° range.

• Surgical treatment is considered when curve magnitude exceeds 50°

• Surgical decision making is complex (the effect of treatment on remaining growth and potential for development of

crankshaft if a single-stage posterior fusion procedure is performed)

• Combined anterior and posterior fusion with posterior instrumentation is an option for older patients

• Innovative growth modulation techniques such as convex disc stapling are under investigation and may offer an option for fusionless correction of scoliosis in the future.

adolescent idiopathic scoliosis

• The most common type of scoliosis in children (prevalence is 3% in the general population)

• A female predominance is noted

• Thoracic curve patterns are generally convex to the right (atypical curve patterns are an indication for MRI)

• Idiopathic scoliosis in adolescence is not typically associated with severe pain

Patient’s Evaluation

Patient history: Includes menstrual history, birth and developmental history, and family history of scoliosis

PHYSICAL EXAMINATION•Height and weight assessment•Observation (look for shoulder, thorax, or waist asymmetry) plumb line•Adams forward bend test. •Use a scoliometer to quantitate asymmetry•Neurologic assessment. •Upper and lower extremity assessment (include gait and leg length evaluation)

RADIOGRAPHIC ASSESSMENT

• A standing posteroanterior (PA) long cassette radiograph is the initial view obtained

• Lateral radiographs • Side-bending radiographs (vulcrum bending x ray)• Pelvis x ray

What to assessed in PA radiograph ???

• curve location, • curve direction, • curve magnitude, • end vertebra, • apical vertebra, and • Risser sign

• Curve location. The curve location is defined by its apexCurve Apex–Cervicothoracic C7 or T1–Thoracic Between T2 and T11–T12 disc–Thoracolumbar T12 or L1–Lumbar Between L1–L2 disc and L4–Lumbosacral L5 or S1

• Curve direction. Curve direction is determined by the side of the convexity.

• Curve magnitude. The Cobb-Lippman technique is used to determine curve magnitude.

Perpendicular lines are drawn in relation to reference lines along the superior endplate of the upper end vertebra and along the inferior endplate of the lower end vertebra. The angle created by the intersection of the two perpendicular lines is termed the Cobb angle and defines the magnitude of the curve.

• End vertebra. The top and bottom vertebra that tilt maximally into the concavity of the curve are termed the end vertebra. They are typically the least rotated and least horizontally displaced vertebra within the curve

• Apical vertebra. The apical vertebra is the central vertebra within a curve. It is typically the least tilted, most rotated, and most horizontally displaced vertebra within a curve

Risserstage 4 correlates with the end of spinal growth in females, and Risser stage 5 correlates with the end of spinal growth in males

Nash-moe system

Side bending x ray

• Side-bending radiographs are used to assess the flexibility of curves that comprise a spinal deformity

• Patient present with a combination of fixed and flexible spinal deformities.

• Curves that correct completely when the patient bends toward the convexity of the curve are termed nonstructural curves.

• Nonstructural curves permit the shoulders and pelvis to remain level to the ground and permit the head to remain centered in the midline above the pelvis.

• For this reason, nonstructural curves are also referred to as compensatory curves.

King-Moe classification

• thoracic curve patterns in idiopathic scoliosis distinguishes five curve types as a guide to surgical treatment

• The King classification does not address lumbar curves, thoracolumbar curves, or triple major curves.

• It does not evaluate sagittal plane alignment.

Type 1: S-shaped curve in which both the thoracic and lumbar curves cross the midline. Both curves are structural, and the lumbar curve may be larger or less flexible than the thoracic curveType 2: S-shaped curve in which the thoracic curve is larger or less flexible than the lumbar curve (also called a “false” double major curve)Type 3: Single thoracic curve without a structural lumbar curveType 4: Long thoracic curve in which L5 is centered over the sacrum and L4 is tilted into the thoracic curveType 5: Double thoracic curve with T1 tilted into the convexity of the upper curve

Lenke Classification

• Lenke and colleagues developed a comprehensive, practical two-dimensional classification system in 2001.

• The Lenke curve classification includes not only thoracic curves, but also thoracolumbar/lumbar curve patterns.

• Additionally, this classification allows the surgeon to assess curves in coronal and sagittal planes

Lenke classification• Based on assessment of PA, lateral, and side-bending radiographs.

• Six curve types are identified

• basic steps in curve classification include:– Determine curve type:

• Measure all curves. Identify the major curve. Determine whether the minor curves arestructural or nonstructural (see Fig. 39-4)

– Determine the lumbar spine modifier: • The six main curve types are subclassified as A, B, or C on relationship ofthe center

sacral vertical line (CSVL) to the lumbar spine

– Determine the thoracic sagittal modifier: • “-”, “N”, or “1” is determined on, the T5 to T12 sagittal Cobb angleThis triad of

radiographic information (curve type 1 lumbar modifier 1 sagittal modifier) is required to determine the curve classification (e.g. 1B1).

Treatment

• Objectives :– 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, orthoses, and operation

observation

• The purpose of observation for adolescent idiopathic scoliosis is to identify and document curve progression and

• Curves less than 20° are observed

risk factors for curve progression

• Future growth potential of the patient (assessed by a variety of factors, including age at presentation, Risser stage, Tanner stage, menarche, peak height velocity, triradiate physeal closure, skeletal age as determined by hand radiographs)

• Curve magnitude at the time of diagnosis

• Curve pattern (double curves progress more frequently than single curves)

• Female sex (curves in females are more likely to progress than curves in males)

• Genetic risk score (ScoliScore Prognostic Test, Axial Biotech)

Risk of progression

• less than 30° at maturity are least likely to progress.

• Curves 30° to 50° degrees are likely to progress an average of 10° to 15° over the course of a normal lifetime.

• Curves measuring 50° to 75° at maturity progress steadily at a rate of approximately 1° per year.

• Lumbar and thoracolumbar curves are more likely to progress than thoracic curves because they lack the inherent stability provided by the rib cage.

Orthosis (Bracing)• spinal orthosis is used to prevent curve progression and generally does not

lead to permanent curve improvement.

• successful brace treatment is the initial correction achieved by 50% or more upon initiation of bracing

• Risser stage 0 to 1 and premenarchal with curves 20° to 29° are candidates for immediate bracing

• Risser stage 2 patient with a curve of 20° to 29°, progression of 5° should be documented before bracing is initiated

- Recent study : - 25% of cases in bracing continue to progress

Contraindication of brace treatment

• Skeletally mature patients

• Curves greater than 40°

• Thoracic lordosis (bracing potentiates cardiopulmonary restriction)

• Patients unable to cope emotionally with treatment

Type of Brace

• CTLSO (Milwaukee brace). Used less commonly due to its cosmetic appearance. However, for curves with an apex above T8, it remains most efficacious

• TLSO (e.g. Boston brace). These lower-profile orthoses are better accepted by patients and are indicated for curves with an apex at T8 or below

• Bending brace (e.g. Charleston brace). This type of brace holds the patient is an acutely bent position in a direction opposite to the curve apex. It is worn only during sleep. It has been advocated as an alternative to full-time bracing regimens

• Flexible brace (e.g. SpineCor brace)

Prognosis

• Factors : – Curve magnitude : more angulation & rotation,

progress more (>20)– Age : younger, progress more (<12yo)– Risser’s score : score 0-1, progress more – Curve length : shorter curves, progress more– Location : higher curves, progress more– Flexibility : stiffer curves, progress more

Operative / Surgery

• Objective :• obtain a solid fusion and to have the top and the

bottom of the fusion balanced within the stable zone

• Indication for surgery :– <30 failed conservative treatment– 30 - 45, with progression– >30 with cosmetically unaccepted in skeletal maturity– Balanced, double curves, if >60 and progressing– Adult with backpain

• With hook constructs, it has been recommended that the distal level be the “stable” vertebra, the one that is intersected or bisected by the center sacral line

• the appropriate level to fix proximally is determined by the sagittal plane as well. In the sagittal plane, the top and the bottom of the fusion should be transitional, in an area of relative lordosis

• Established teaching was that posterior fusion should stop two levels above and one level below the transitional segments

• Those levels can at times be shortened if fixation is achieved at every level with hooks or pedicle screws and if the “saving of levels” is compatible with the sagittal plane

Operative / Surgery

• Goals :– Halting progression– Achieve correction– Achieve spinal balance

• Objectives :– Reduce rotational deformity & lateral deviation– Athrodese the primary curve

Operative / Surgery

Types :• Posterior approach• Anterior approach• Combined posterior & anterior approach• Video-assisted Thoracoscopic Surgery (VATS)

Posterior Approach• 1960’s : Harrington system

• 1970’s : Segmental fixation– Moe fusion technique– Luque method

• 1980’s : Cotrel-Dubousset (CD) instrumentation – Stronger fixation no post-operative bracing– Better correction in 3 dimensions (derotation)

Posterior Approach

• 1990’s : Pedicle screws – Reduce the number of fusion levels reduce the number

of junctional problems

– The Moss Miami Instrumentation System

Subroto Sapardan– PSSW ( Pedicle Screw Sublaminary Wiring) – University of Indonesia (UI) System

Harrington Instrumentation

LUQUELUQUE GALVESTON

HARRINGTON

LUQUE

WISCONSIN

Cotrel-Dubousset (CD) instrumentation

Anterior Approach

• Dwyer / Zielke : – Disc excision followed by compression across the

disc– The use of a solid rod & screw system – The use of two solid rods – Thoracoplasty : to reduce the size of the rib hump

DWYER INSTRUMENTATION

ZIELKE INSTRUMENTATION

Video-Assisted Thoracoscopic Surgery (VATS)

• Minimally invasive surgery• Smaller incisions to insert a screw at each

level and a single rod

Video-Assisted Thoracoscopic Surgery (VATS)

Discectomy Intervertebral Disc Removal

Endplate Removal

C-Arm Fluoroscopic View of Vertebral Screw Insertion

ECIF (External Correction Internal Fixation)

FOR SCOLIOSIS

THANK YOU