Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital Jaipur Scoliosis - Basics Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital Jaipur

What is scoliosis Demographics & Etiology Clinical Evaluation Radiological Evaluation Treatment

Scoliosis “Abnormal lateral curvature of spine” Deformity in the coronal plane

3 Dimensional Deformity Coronal Plane Sagittal Plane Axial Plane

3 Dimentional Deformity

Demographics Occurs in 1-3% of population below the age of 16 years. 0.1% have a curve greater than 40 degrees. Girls are more affected than boys. Those with a curve of more than 30 degrees are generally girls, outnumbering boys by 10:1.

Types of Scoliosis Congenital Neuromuscular Syndromic Idiopathic – Cerebral palsy / PPRP Syndromic Marfan’s syndrome Neurofibromatosis Idiopathic – 80% - Most common Degenerative

Idiopathic - Classification Infantile: 0-3 years old (.5%) Juvenile: 4-10 years old (10.5%) Adolescent: 10-17 years old (89%) Early Onset : 5 years or less Late Onset: more than 5 years

Anatomy All bony elements are altered Discs are wedged as well Vertebra are wedge shaped Poorly Developed Concave side Pedicles rotated Discs are wedged as well

Etiological Theories Genetic Tissue deficiencies Growth abnormalities Central nervous system alteration

Genetic Strongly Familial 11% incidence in first relatives of patients Normal incidence < 3% Monozygote twins more common Gene identified – Chromosome 3p26. LBX1, DSCAM gene

Tissue Deficiencies Marfan’s syndrome deficient fibrillin Osteopenia noted in girls Elevated calmodulin Involved in contractile properties thru actin & myosin Elevated in platelets No consistent findings to date

Growth Abnormality Asymmetrical vertebral growth Hueter-Volkman effect is suppression of growth on concave side Hypokyphosis during growth spurt No increased incidence with growth hormone No initiating factor identified

Central Nervous System Different size cerebral cortices Associated Syrinx, Low lying cord, Arnold Chiari Malformation –Functional Spinal Cord Tethering Deficient melatonin Chicken model Inconclusive in humans

History First noted and progression Family history Affected sibling 7 times more frequent Affected parent 3 times more frequent Recent growth history Sexual maturity Pain ‘Fatigue pain’ Post diagnostic pain ‘Severe pain’

Physical Exam Iliac crest height Shoulder height Arm trunk space Leg length discrepancy Shoulder height Arm trunk space Scapular position Trunk shift Neuro exam /Muscle charting Generalized Features – Marfan’s Inspection of skin Café au lait spots Hair patch

Physical Examination: Features suggestive of polio, neurofibromatosis, Von Reclinghausen syndrome, Down’s, Marfan’s, Hurler’s syndrome, neural tube defects and osteogenesis imperfecta. Forward protrusion of chest wall on affected side. Increased flank creases on opposite side. Higher ASIS and PSIS on concave side. Spinous process turned into concave side.

Forward Bend Test Adam’s sign

Radiological Evaluation PA & Lateral Whole Spine Standing Films Posterior to anterior Decrease thyroid and breast exposure 3-7 fold AP – Whole spine right and left bending films – lying down Traction X-rays Fulcrum Bend X-rays

Scoliosis – Analyzing Curve Structural and Non Structural Primary Curve and Secondary Curve End vertebra Apex Cobb’s Angle Stable zone Rotation

Structural Curve – Position Independent Fixed deformity Structural changes

Primary Curve Structural Lateral Curvature with Rotation Recognized Clinically Measured Radiographically End Vertebra Most tilted vertebra Last to show rotation of Spinous process Pedicle width equal on each side Neutral Disc / Neutral Vertebra

Compensatory Curves Above and below the primary curve In opposite direction to primary curve No fixed clinical rotation “Righting Reflex”

Measurement of Scoliosis Cobb’s Angle

Rotation Spinous process rotates into concavity Nash & Moe method - Pedicle position

Stable Zone / Stable Vertebra

Nomenclature Cervical – C1 to C6-7 Disc Cervicothoracic – C7 to T1 Thoracic – T1-2 Disc to T11-12 Disc Thoracolumbar – T12 to L1 Lumbar – L1-2 Disc to L4-5 Disc Lumbosacral –L5 and below

T5 T9 Compansatory Curve 760 L1

Skeletal Maturity History and Physical Exam Triradiate cartilage fusion Risser sign

King’s Classification Double curve, both curve cross the midline, • Lumbar curve larger , stiffer than the thoracic curve Double curve, both cross the midline • Thoracic curve larger, stiffer than the lumbar curves. Long thoracic curve in which L5 is centered over sacrum but L4 tilts into long thoracic curve Thoracic curve and T1 tilts to upper curve Thoracic curve crosses midline and lumbar curve does not cross midline

Lenke Classification

MRI Neurologic deficit Infantile and juvenile curves Spinal cord abnormality in younger children Infantile idiopathic scoliosis 50% Juvenile 20%

Who needs an MRI: A thoracic curve to the left. Painful scoliosis. Abnormal neurological findings. Untoward stiffness. Deviation to one side during the bend test. Sudden rapid progression of a previously stable curve.

Treatment

Natural History - Curve Progression Curves 30 to 50 degrees progress an average of 10 to 15 degrees over a lifetime. Curves > 50 at maturity progress steadily at a rate of 1 degree per year. Curves less than 30 at bone maturity are unlikely to progress.

Medical complications: At 90 degrees or greater: increased potential for life threatening effects on pulmonary function. Psychologic illness: seen in up to 19% of females with curves great than 40 degrees as adults.

Natural History Close relationship b/w increase in height & curve progression Infantile rapid stage Juvenile slow stage Adolescent rapid stage Mature – slow stage

Will the curve progress? Three factors involved in progression Patient’s gender – Females are 10 times more likely to have progression than males. Future growth potential – Skeletal Maturity – Radiological / clinical Curve magnitude at time of diagnosis The greater the growth potential and larger the curve = more likely to progress

Treatment Observation Bracing Surgery

Treatment RISSER CURVE Action 0 - 1 0 - 20 degrees 20 - 40 degrees Observe Brace 2 - 3 0 - 30 degrees 30 – 40 degrees 0 - 3 0 - 4 40 – 50 degrees 50 degrees and higher Gray Surgery

Bracing Orthotic braces - 74% success rate at halting progression Must be worn 20-23 hours a day, but most pts are not compliant. Braces do not correct scoliosis.

Braces

Bracing - Contraindications Curves >450 Patient with noticeable Trunk shift Skeletally mature adolescents – Riser 4-5, 2 yrs post menarchal Curve apex above T6 Excessive Thoracic Hypokyphosis < 200

Scoliosis - Surgery Fusion – gold standard Creating a well balanced spine – both Sagittal and Coronal plane Instrumentation – to maintain acceptable alignment Non-fusion options - developmental

Surgery Anterior Release Anterior Instrumenation Posterior Instrumentation Osteotomies - Ponte’s VCR Growth rods

Tests of flexibility of spine: Adam’s forward bending test. Pushing the curve from convex side and noting the correction. Lifting the patient up from head. X-rays - Lateral bending / Fulcrum bend /Traction X-Rays

Early Onset Scoliosis Preserve as much growth potential as possible Lung development Thoracic insufficiency syndrome

Infantile Treatment Must prove idiopathic 90% are left thoracic 3 female : 2 male 90% resolve spontaneously Predict progression by RVAD < 20 degrees 83% resolve >20 degrees 84% progress

Congenital Scoliosis Vertebral malformation Rib Anomalies Failure of formation Failure of segmentation Mixed Rib Anomalies Spinal cord anomalies Urogenital / Cardiac

Growing Rod Technique

Conclusion Scoliosis is common – most are lordoscoliosis Treatment depends on remaining growth potential, curve magniitude, and sex Goal of treatment is to have a curve of <45-500 at Skeletal Maturity Bracing Surgery

Thank You Dr. Lalit Sharma lalitspine@gmail.com Consultant Spine Surgeon Narayana Hrudayalaya Hospital Jaipur lalitspine@gmail.com