|
|
Scoliosis
and Spinal Deformity
|
| |
Scoliosis (Classification)
- Idiopathic
a. Infantile (0-3 years)
b. Juvenile (3-10 years)
c. Adolescent (>10
yrs) see examples
d. Adult (>18
years)
see
examples
- Neuromuscular
a. Neurophatic
b. Myopathic
- Congenial
a. Failure of formations
b. Failure of segmentations
- Neurofibromatosis
- Mesencymal disorders
- Rheumatoid Disease
- Trauma
- Extraspinal Contractures
- Osteochondrodystrophies
- Infection of Bone
- Metabolic disorders
- Related lumbosacral joint
- Tumors
Kyphosis
- Postural
- Scheuermanns’s
disease
- Congenital
- Neuromuscular
- Myelomeningocele
- Traumatic
- Post-surgical
- Post-irradiation
- Metabolic
- Skeletal dysplasias
- Collagen disease
- Tumor
- Inflammatory
Lordosis
- Postural
- Congenital
- Neuromuscular
- Post-laminectomy
|
|
The
normal spine is straight in the frontal plane, whereas
in the sagittal plane it is composed of three curves:
a cervical lordosis, a thoracic kyphosis and a lumbar
lordosis.
Deviations in normal spinal contours comprise a group of disorders
termed spinal deformities of which idiopathic scoliosis is the most
common. Spinal deformities are clinically important because they may
produce pain, difficulty with sitting or ambulating, neurologic compromise,
unacceptable cosmesis and in advanced cases cardiopulmonary compromise.
Each type of spinal deformity is associated with its own clinical presentation,
symptoms and natural history for progression.
Although
scoliosis has been defined as lateral curvature of
the spine, it is associated with vertebral rotation,
which produces the cosmetically unacceptable rub
hump. Idiopathic Scoliosis is classified according
to the age at onset: infantile, juvenile and adolescent.
Scoliosis seen after skeletal maturity is termed
adult scoliosis. Progression of idiopathic curves
correlates with the magnitude of the curve, the age
of presentation and the patient’s menarchal
status. Non-idiopathic causes of scoliosis must be
determined because of their less predictable, and
generally higher risk for progression (e.g. congenital,
neurofibromatosis and neuromuscular).
|
| Symptoms
and Signs: |
Examination
of the patient with spinal deformity should include determination
of the patient’s overall frontal and sagittal alignment
with particular attention to the relationship of the
occiput with the sacrum. When the occiput is not centered
over the sacrum, the patient is described as decompensated.
Asymmetry of the shoulders and the pelvis may be present
with high thoracic and lumbar curves, respectively. The
skin should be carefully inspected for signs of café-au-lait
spots (neurofibromatosis) or hair patches (spinal dysraphism).
The forward bend test detects the rib hump, which correlates
with curve magnitude and vertebral rotation. Bowel and
bladder history and a complete neurological examination
are mandatory for all patients.
Significant
pain or neurological symptoms are uncommon with adolescent
idiopathic scoliosis. These findings warrant further
investigation to rule out tumor, infection, disc
herniation, or other non-idiopathic causes of spinal
deformity.
|
Imaging: |
 Patients
referred for evaluation of spinal deformities should
obtain standing AP and lateral radiographs including
the entire spine (36"x14" film). If treatment
is contemplated, bending films in the direction of
each curve convexity will help to determine curve flexibility.
Curves are measured according to the Cobb Method. The
vertebrae, which are maximally tilted into the concavity
of the curve, are the end vertebrae. Perpendiculars
from their endplates are drawn and the angle between
them determines the curve magnitude. Curves should
be measured from the same vertebrae during each examination
for serial comparison.
Patients
presenting with neurological signs or symptoms, left
thoracic curves or rapid progression should obtain
magnetic resonance scans to rule out intraspinal
pathology.
|
|
Treatment
of Adolescent Idiopathic Scoliosis |
| Observation: |
Skeletally
immature patients presenting curves less than 20 degrees
or for those presenting with curves less than 40 degrees
at skeletal maturity should be observed. Adolescent
patients should be followed with radiographs at 4-6
month intervals until skeletal maturity.
Curves
greater than 20 degrees or progression of greater
than 5 degrees should be referred for treatment to
a surgeon experienced in the management of patients
with spinal deformity.
|
| Bracing: |
 Growing
children with curves measuring 20-40 degrees or documented
progression are candidates for brace treatment. Patients
with curve apices below T8 can be fitted with polypropylene
underarm type braces. Higher curves can only be controlled
with a cervico-thoracic-lumbar orthosis (Milwaukee
Brace). The goal of bracing is to halt progression.
Long-term curve correction is rarely achieved with
brace treatment.
The
daily duration of brace wear is necessary to halt
progression is controversial. Although historically
braces have been worn for 23-24 hours per day, recent
studies have indicated that limited daily brace wear
may be equally effective. Generally, patients should
be braced until skeletal maturity and then should
be gradually weaned. For bracing instructions, click here. |
Surgical
Treatment:
|
|
Patient with lumbar Scoliosis
has complete correction of curve with anterior
instrumentation technique. |
| |
|
|
|
| Patient treated with
a posterior Spinal Fusion for Thoracic Scoliosis. |
| The
prevalence of patients with curves greater than 20
degrees is 0.13 to 0.30 percent with few of them requiring
surgery. Progressive curves, those 40 degrees or greater,
and those resistant or non amenable to brace treatment
are indicated for surgery. Newer surgical techniques
are designed to both correct the frontal curve and
decrease vertebral rotation whole providing secure
fixation so that post-operative brace wear is often
not needed. Instrumentation is accompanied by surgical
fusion with bone grafting. Anterior fusion and instrumentation
has been developed for certain lumbar curves. The length
of the fusion depends on the type of curve treated.
The preservation of lumbar motion segments below the
fusion has been shown to correlated with a decreased
incidence of low back pain in the adult patient.
We have the largest Spinal Deformity practice in the West. This is in
large part due to our super-specialization in Scoliosis and Complex Scoliosis
Revision surgery. We have a specialized spine team consisting of pain
management, orthopedic surgeons, vascular surgeons, OR techs and nurses
who exclusively work spine surgical procedures, and a designated anesthiologist.
If you would like more information about please call (310) 423-9983 to
schedule an appointment with Dr. Pashman. Or email us at eSpine1@aol.com
Related links:
Adolescent Idiopathic
Scoliosis
Adolescent Idiopathic Scoliosis surgical
case examples
Patient Journal
of Scoliosis Surgery
Patient
follow-up journal four years after surgery
Adult Idiopathic
Scoliosis
Adult Idiopathic
Scoliosis surgical case examples
Scoliosis FAQ's
Obtain a second opinion
on your scoliosis surgery
|
|
