1. Scoliosis
Mr. Christopher I. Adams

2. National Services Division - “Spinal Surgery”
Year
Budget
Procedures
No.
2005 / 06
2,746,093
109
2006 / 07
2,912,821
145
2007 / 08
3,124,282
201
2008 / 09 ?
213
2009 / 10
239
2010 / 11
4,910,000 (78%)
259 (137%)

3. OCAP & FRCS (Tr and Orth) / ST3-6
Applied Clinical Knowledge Syllabus
The Spine (Sec. 8-13)
“A basic knowledge of the surgery of spinal deformity and tumours of the spine”. Competence level 3 = “Knows generally”.
Paediatric Orthopaedic Surgery (Sec. 8-14)
“Knowledge of the neurological processes involved in the production of deformity e.g. spina bifida, cerebral palsy and muscular dystrophy”. Competence level 3 = “Knows generally”.
Clinical Procedures Syllabus
Thoracic Spine – Scoliosis correction – posterior (Sec. 8-24)
Competence level 1 = “Has observed or knows of”.
ST7-8, Competence level 3s = “Can manage whole but may need assistance”.
Interrupt at any time for questions…if you are thinking it, so are others.

4. Today’s Plan Pathology Measuring Scoliosis Treating Scoliosis
Differences when not idiopathic
Congenital
Handout
All references
Crib sheet

5. Classification - Pathology
Idiopathic (36%)
Neuromuscular (21%)
Duchenne = 15 patients
Congenital (10%)
West of Scotland clinics = 414pts
2yr 10m, 26 Nov 2006 to 15 Sept 2009

6. Clinical Assessment History Examination deformity pain general health
development & maturity
family history
Examination
general (diagnosis)
specific (deformity)

7. General Examination General appearances Skin Joint laxity
palate, ears, neck
Skin
hair patches, skin dimples
scars
café au lait patches
Joint laxity
Spinal dysraphism
leg length, foot size inequality
foot deformities
asymmetric abdominal reflexes

8. Examination of the Back

9. Quantifying Spinal DeformityC7 T3 T5 T7 T9
T11 L1 L3 L4
Sacrum

10. Surface and Spine Measures
Bunnell WP.
JBJS [Am] 1984; 66-A:

11. Clinical and Surface Topography

12. Cobb Angle θ
Outline for the Study of Scoliosis. Cobb, John R. (New York, New York, U.S.A.) American Academy Instructional Course Lectures 1948;Vol. 5: pg 266.

13. Classification - Type of curve - OLD

14. Classification - Type of curve
Lenke

15. Spinal Height Gain (cm/yr)
Spinal Growth
Spinal Growth Velocity
Risser Sign
Spinal Height Gain (cm/yr)
Age

16. GROWTH VELOCITY OF THE SPINE
3 months later

17. Scoliosis Progression
Younger patients + large curves = great risk of progression
Increased growth  greater deformity
Larger curves (> 50º)  spontaneous buckling
Progression in adulthood
98o
130 cm

18. The Spinal - Rib Cage Connection
Nash and Moe. A Study of Vertebral Rotation.
JBJS [Am] 1969; 51-A:

19. Objectives of Surgery Cosmesis
Prevention of curve progression
Correction of curve
Reduce the cardio-pulmonary consequences of scoliosis
Avoid neurological complications

20. Posterior Spinal Surgery Case ♀ - AIS
66%

21. Pedicle Screw Constructs - Idiopathic Scoliosis
15yrs 1mth
15yrs 5mth
58 o
23 o
45 o
23 o

22. Anterior Release & Costoplasty

23. Intra-operative Monitoring - European Literature
“Reviewing the literature on intraoperative monitoring makes it clear that application of a single method such as SEPs is not sufficient and that accounting for ascending and descending pathways of the spinal cord and nerve roots requires a multimodal approach.”
Current opinion and recommendations on multimodal IOM during spine surgeries. With Spinal Osteotomy. Sutter M, Delitis V, et al. (Multicentre) Eur Spine J 2007;16 (Supp2): pg S232-7. 23

24. Intra-operative Monitoring - Literature
Paper
Year
(pub)
Deformity
IOM +ve
Neurology
Bridwell
n= 500pt
(1998)
Scoliosis ?
0.01% to 0.05%
SRS
n=670pt
2001-4
Kyphosis
0.4%
Vitale
n=151pt
(2010) 8%
1.3%
Lenke
n=42pt
(2008)
21%
2.4%
(recovered)
U.K.
N=~1400 24

25. Syrinx Retrospective 1992 – 2005 n = 13 11 yrs 1 mth (3.6–16.4 years)
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland) Spine 2007;32 (21): pg

26. Syrinx All fusion surgery No neurological deterioration
4vs= 4th ventriculo-arachnoid shunt
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland) Spine 2007;32 (21): pg

27. Syrinx – Case ♀ 13y10m Hx fall off trampoline 2yrs
Left mid thoracic back pain, no radiation.
Neurology
Symm. Absent abdominal reflexes

28. Syrinx – Case ♀

29. Posterior decompression
Syrinx – Case ♀
Posterior decompression
by Miss Lynn Myles
16/09/2009

30. “Superior Mesenteric Artery Syndrome in Paediatric Orthopaedic Patients”
1842 Rokitansky
N = 14 pts
1979 to 1987
Presentation
Nausea
Intemittent and large bile-stained vomiting
Between normal appetite
Bowel sounds present
“SMA syndrome in paediatric ortho pts”
Hutchinson DT and Bassett GS.
from Ann Arbor, Michigan, USA
Clin Orth and Rel Research 1990 ;250:pg250-7.

31. Changing Practice - Spina Bifida
2yrs 8mth
196
17yr 2m
164
Only 10% no spinal deformity
JBJS Br 1980; 62-B: p54-8
6 to 12 degrees per yr

32. Spina Bifida - Case ♀ 8y8m Pre-menarche Braced since 18mths
Now tripod sitting
Motor level L1
VP shunt
Vesicostomy
PEG
Painless right hip dislocation
Picture
no97

33. Spina Bifida - Case ♀
no97

34. Spina Bifida - Case ♀ 26.07.2007 31.07.2007 8yrs 9mth 8yrs 9mth no97

35. Spina Bifida - Case ♀ Outcome
8yrs 8m
9yrs 2m
Brace
NO brace
no97

36. Surgical Objectives Preserve Neurology Spinal and pelvic alignment
bowel and bladder
sensation
use of legs
Spinal and pelvic alignment
Level shoulders & pelvis
CoG over sacrum
Unaided sitting with stability
Relationship to the hip
Avoid other complications

37. Congenital

38. Congenital “Congenital deformities of the spine” McMaster MJ
J R Coll Surg Edinb 2002;47:p475-80

39. Congenital - Case ♂

40. Discussion / Comments / Questions…