Transcript Idiopathic Scoliosis” - Orthopaedic, Pediatric & Spine

“Idiopathic Scoliosis”
Dr. Donald W. Kucharzyk
Clinical Assistant Professor
University of Chicago
Children’s Hospital
“Idiopathic Scoliosis”
• Defines a common and potentially severe
musculoskeletal disorder
• The term scoliosis is derived from the
Greek word meaning “crooked” as first
used by Galen in 131 A.D.
• References are made to scoliosis since
ancient times as seen in ‘Corpus
Hippocraticum’
“Idiopathic Scoliosis”
“Etiology”
• Remains unknown
• Several studies have attempted to look
into this and various factors have been
postulated: genetic, tissue deficiencies,
vertebral growth abnormalities, and
central nervous system theories
“Idiopathic Scoliosis”
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“Genetic Factors”
Risenborough found a 11.1% incidence of
scoliosis in first born relatives of patients
with idiopathic scoliosis
Twins show a concordance of scoliosis
with an incidence of 92% monozygotic and
63% dizygotic
“Idiopathic Scoliosis”
“Genetic Factors”
• Despite this confirming evidence of a
genetic etiology, the gene and gene
products responsible for the development
of idiopathic scoliosis remains still
unknown
“Idiopathic Scoliosis”
“Tissue Deficiencies”
• Primary pathology centered in the
structural tissues of the spine
• Fibrous Dysplasia results in dysplastic,
mis-shapened vertebrae
• Muscle disorders such as Duchene’s lead
to a collapsing scoliosis
“Idiopathic Scoliosis”
“Tissue Deficiencies”
• Soft tissue collagen disorders such as
Marfan’s have a clear association with
scoliosis (defect in fibrillin)
• Osteopenia has been associated with
idiopathic scoliosis…bone mineral density
lower in girls aged 12 to 14 than a matched
control with scoliosis: mechanism unknown
“Idiopathic Scoliosis”
“Vertebral Growth Abnormality”
• Milner and Dickson postulated a
differential growth rates between the
right and left sides of the spine
• Results in abnormal biomechanical loading
of the spine: Heuter-Volkmann effect
“Idiopathic Scoliosis”
“Vertebral Growth Abnormality”
• Dickson postulated a discrepancy between
growths of the anterior and posterior spinal
columns
• Irregularities in the sagittal shape of the
spine during rapid adolescent growth may
contribute to development of scoliosis
• Scoliotic patients are taller and thinner
“Idiopathic Scoliosis”
“Central Nervous System”
• Goldberg noted greater asymmetry of the
cerebral cortices
• Abnormalities in equilibrium and vestibular
functions have been noted in scoliosis
patients
• Melatonin and the pineal gland has been
postulated
“Idiopathic Scoliosis”
“Central Nervous System”
• Malchida et al, Hilibrand et al, and Bagnall
et al have all looked at melatonin levels in
blood and urine
• Paraspinal muscle histology revealed
denervation changes, also sarcolemma
changes were seen at the myotendinous
junction supporting a neuropathic cause
“Idiopathic Scoliosis”
“Natural History”
• Understanding this is essential to
determining when treatment is necessary
• Few natural history studies examine
curve progression in the untreated
skeletally immature population
“Idiopathic Scoliosis”
“Natural History”
• Curves under 20 degree’s are are low
risk for progression
• Certain factors due influence the natural
history: sex, remaining growth, curve
magnitude, and curve pattern
“Idiopathic Scoliosis”
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“Natural History”
Sex: females progress the most
Remaining Growth: Risser sign, Menarchal
status, and Peak Height Velocity
Curve Magnitude: ‘Lonstein et al”
Curve Pattern: Double curves and thoracic
curves likely to progress followed by
thoracolumbar and lumbar
“Idiopathic Scoliosis”
“Classification”
• Curve Location:
cervical apex C2-C6
Cervicothoracic apex C7-T1
Thoracic apex T2-T12
Thoraocolumbar apex T12-L1
Lumbar apex L2-L4
“Idiopathic Scoliosis”
“Classification”
• Age at Onset:
Infantile: age birth to 3 years
Juvenile: age 4 to 10 years
Adolescent: age 11 to 17 years
Adult: age 18 years up
“Idiopathic Scoliosis”
“Prevalence”
• 0.5 to 3 per 100 (curves over 10
degrees)
• 1.5 to 3 per 1000 (curves over 30
degrees)
• Based upon age types: 0.5% infantile,
10.5% juvenile, and 89% adolescent
“Idiopathic Scoliosis”
“Prevalence”
• When a sibling or parent has scoliosis:
seven fold increase(sibling) and three
fold increase(parent) compared to
general population
“Idiopathic Scoliosis”
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“Clinical Features”
Pain: not a common complaint.
Discomfort can be a common feature but
not severe pain.
‘Ramirez et al’ noted mild back discomfort
and fatigue in 23%
If severe pain: must question etiology of
the idiopathic curve
“Idiopathic Scoliosis”
“Clinical Examination”
• Evaluation of trunk shape, trunk balance,
neurologic system, limb length, skin
markings and any skeletal abnormalities
• Adams forward bend test
• Radiologic Assessment: standing PA and
lateral
“Idiopathic Scoliosis”
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“Interpretation of Scoliosis Film”
Soft tissue abnormalities
Congenital bony abnormalities
Pedicle appearance and width
Curve assessment (Cobb Method)
Vertebral rotation (Nash and Moe)
Skeletal Maturity
“Idiopathic Scoliosis”
“Curve Pattern Classification”
• King-Moe Classification:
King I: Rt T Lt L
lumbar larger
King II: Rt T Lt L thoracic larger
King III: Rt Thoracic
King IV: Long Thoracolumbar
King V: Double thoracic
“Idiopathic Scoliosis”
“Curve Pattern Classification”
• Lenke Classification: more comprehensive
and considers both frontal and sagittal
plane deformity
• Currently being evaluated for
practicality and usefulness
• ‘Spine Volume 26 Number 21
Nov. 1, 2001’
“Idiopathic Scoliosis”
“General Treatment Concepts”
OBSERVATION
• No treatment needed if curve magnitude
under 25 degrees
• Repeat evaluation in 3 to 4 months
• If 7 to 10 degree change then
considered progression and treatment
needed
“Idiopathic Scoliosis”
“General Treatment Concepts”
BRACE TREATMENT
• Nachemson 1995: effectiveness of
bracing versus observation…bracing better
• Types of braces available: Milwaukee,
TLSO(Boston), Charleston Bending Brace,
SpineCor
• Brace wear duration
“Idiopathic Scoliosis”
“Types of Braces”
• Milwaukee and Boston: data supports good
results with either
• Charleston Bending Brace: variable
results; “Price et al” 79% success “Katz
et al” Boston vs Charleston and Boston
better “Howard et al” compared all three
with Boston/TLSO better of the three
“Idiopathic Scoliosis”
“Types of Braces”
• Griffet et al: “SpineCor system”
worn as an undergarment
allows normal spine movement while applying
a dynamic corrective force
limitation: progressive curves under
30 degrees
initial data is promising
“Idiopathic Scoliosis”
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BRACE TREATMENT
Brace treatment is effective
Does change the Natural History
Full-time use better than part-time
“Rowe et al: 23 hrs better”
Indications: progressive curves over 25
degrees; initial curve presentation of
between 30 and 40 degrees
“Idiopathic Scoliosis”
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BRACE TREATMENT
In brace radiographs are important and
obtained in 2 to 4 weeks
40 to 50% correction for Boston
70 to 90% correction for Charleston
Insufficient in-brace correction leads to
unsatisfactory outcomes
“Idiopathic Scoliosis”
SURGICAL CORRECTION
GOALS
• Reduce the magnitude of the curve
• Obtain fusion to prevent progression
• Create a well-balanced spine
“Idiopathic Scoliosis”
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SURGICAL CORRECTION
INDICATIONS
Curves over 45 degrees
Trunk deformity(rotation)
Trunk balance
Progressive curves despite bracing
“Idiopathic Scoliosis”
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SURGICAL CORRECTION
INSTRUMENTATION
Harrington
Luque
Cotrel-Dubousset
TRSH
Isola
Colorado II
“Idiopathic Scoliosis”
SURGICAL CORRECTION
MECHANISM OF CORRECTION
• Frontal plane realignment through
translation
• Distraction increases thoracic kyphosis and
reduces the scoliosis
• Compression corrects the scoliosis and
restores maintains lumbar lordosis
“Idiopathic Scoliosis”
SURGICAL CORRECTION
“Newer Techniques”
• Pedicular screws: Suk et al reported
better frontal plane correction and
improved de-rotation
• Hammill et al reported that screws reduced
end vertebra tilt better than with hooks
“Idiopathic Scoliosis”
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SURGICAL CORRECTION
“ANTERIOR APPROACH”
Used to mobilize a large curve in conjunction
with posterior fusion
Limits the number of segments to be fused
in thoracolumbar/thoracic curves
Allows anterior instrumentation
Eliminates crankshaft phenomenon
“Idiopathic Scoliosis”
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SURGICAL CORRECTION
“ANTERIOR APPROACH”
Dwyer and Schafer were the first
Kaneda et al: positive results
Betz et al: re-established kyphosis
Picetti and Crawford et al: endoscopic
release and instrumentation resulted in less
pain, improved muscle function and smaller
incisions
“Idiopathic Scoliosis”
OUTCOME OF SURGICAL
INTERVENTION
• Harrington: 48% coronal improvement
• CD: 61% coronal and sagittal plane
improvement
• Anterior correction: 58% improvement
“Idiopathic Scoliosis”
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GENERAL GUIDELINES FOR
TREATMENT OF SCOLIOSIS
Under 20 degree’s: observe
20 to 30 degree’s: observe with frequent
follow-up; progression then brace
30 to 45 degree’s: brace unless Risser 4/5
then observe
45 plus degree’s: instrumentation
“Idiopathic Scoliosis”
THANK YOU