Scoliosis & Kyphosis PDF

- Cobb , angle Definition of scoliosis: explainea Spinal curvature in...

- Cobb , angle Definition of scoliosis: explainea Spinal curvature in the coronal plane of >10° Loading… Scoliosis is a three-dimensional deformity: coronal, sagittal, and axial (rotation) planes. The problem with scoliosis is that the spine is a fixed structure at both the superior and inferior ends. If one side of the spine grows faster than the other, it will begin to bend. The side that grows faster will cause a lateral bend, leading to coronal curvature. If the anterior column grows faster than the posterior column, it results in lordosis. Additionally, the spine may start to rotate, leading to a twisting deformity. Dr Osama Aldahamsheh  SCOLIOSIS IS A 3-D DEFORMITY In the thoracic area, if scoliosis occurs and the spine rotates in the axial plane, it also affects the ribs, causing them to move along with the rotation of the spine. Dr Osama Aldahamsheh  TYPES Of scoliosis Idiopathic Unknown cause Congenital Loading… Developmental or Syndromic Neuromuscular Pathologic or neoplastic Pathological scoliosis can occur, especially in infants who undergo cardiac surgery where one of the ribs is removed. This leads to changes in spinal mechanics, as the forces on either side of the spine become imbalanced. As the child grows, this imbalance can result in thoracogenic scoliosis. Dr Osama Aldahamsheh  HISTORICALLY CLASSIFICATION Classification is good for communication between doctors to understand the cases By age By etiology Dr Osama Aldahamsheh  NEW CLASSIFICATION : EOS" Early onset scoliosis (2014) Scoliosis with onset less than the age of 10 years, regardless of etiology Developed in 2014 by SRS Adolescent idiopathic scoliosis Scoliosis with onset at age 10 years and above, idiopathic cause - most Dr Osama Aldahamsheh common  NEW CLASSIFICATION Early onset scoliosis Idiopathic a structural abnormality or asymmetry of the spine Congenital Structural abnormality or asymmetry of the spine Neuromuscular Cerebral palsy/ Spinal muscular atrophy /Myelomeningocele…etc Syndromic Marfan Syndrome, NF, Skeletal Dysplasia..etc Dr Osama Aldahamsheh  GOALS OF TREATMENT Prevent progression Correct deformity G Correction is performed as much as possible, depending on the status of the spinal cord. The spinal cord is housed within the vertebral column, anchored superiorly by the brain and inferiorly by the filum terminale. It is crucial to ensure that the spinal cord is not damaged during the correction of scoliosis Dr Osama Aldahamsheh  DEFINITION Spinal curvature in the coronal plane of >10° 3D deformation Diagnosis of exclusion No syndromic, congenital, or neuromuscular causes Incidence of Loading… 3% for curves between 10 to 20° => not all need surgery 0.3% for curves > 30° => need Surgery 10:1 female-to-male ratio for curves > 30° The right thoracic curve is the most common left thoracic curves are rare and indicate an MRI to rule out cyst or syrinx Es Considered an atypical curve and MRI is needed Dr Osama Aldahamsheh  ETIOLOGY Cause is unknown “idiopathic” Multifactorial with genetic predisposing factors Developmental and genetic predisposition is found Genetic component If a patient is diagnosed with scoliosis, it is important to inquire whether they have younger siblings for early screening. Early diagnosis is crucial, as timely intervention can prevent the need for surgery. Often seen in multiple members of a family↳ Concordance in 73% of monozygotic twins and 36% of dizygotic twins 11% risk to first-degree relatives, 2.4% risk to second-degree relatives, and 1.4% to third-degree relations Dr Osama Aldahamsheh Not all patients with scoliosis have the same prognosis. Each case of scoliosis is unique, with specific personality. Differences in prognosis are influenced by various genetic factors. Genetics and pathogenesis of scoliosis Petrosyan, Edgar et al. North American Spine Society Journal (NASSJ), Volume 20, 100556 Dr Osama Aldahamsheh  PATHOGENESIS Abnormal development of neurocentral synchondrosis (NCS) Cartilaginous plate that forms between the centrum and posterior neural arches Closure occurs in characteristic order cervical NCS by 5-6 years old lumbar NCS by 11-12 years old thoracic NCS by 14-17 years old Dr Osama Aldahamsheh Olstad, K., Aasmundstad, T., Kongsro, J. et al. Osteochondrosis and other lesions in all intervertebral, articular process and rib joints from occiput to sacrum in pigs with poor back conformation, and relationship to Pathogenesis of scoliosis Primary Ossification Centers: - Initial sites where cartilage is formed and converted to bone. - This process begins early in fetal development. Secondary Ossification Centers: - Emerge later, typically after birth. - Responsible for further bone development in specific regions, including the vertebrae and other bones. Neurocentral Synchondrosis: - A cartilaginous structure located between the anterior and middle columns of the vertebrae. - serves as a growth plate between the vertebral body and the neural arch, allowing for continued growth and development of the vertebrae. Until adulthood where it ossifies. Abnormalities in Scoliosis: - Abnormalities can occur at the neurocentral synchondrosis, potentially contributing to the development and progression of spinal deformities. - These abnormalities may interfere with normal growth and alignment of the vertebrae, leading to asymmetric curvature of the spine. Growth Disparities: - Abnormalities in the synchondrosis can lead to uneven growth of the anterior and posterior columns of the vertebrae. - This disparity in growth can contribute to rotational deformities of the spine, which are characteristic of scoliosis.  CLINICAL ASSESSMENT Hx (School screenings / Parent or patient notice a change in appearance/incidental) HPI Onset Progression Pain Bowel bladder function Physical activity Pt expectation Family Hx PMH PSH Dr Osama Aldahamsheh Allergy: Clinical assessment The goals of taking a patient history are : Establish a proper diagnosis Assess potential familial implications and early diagnosis for other siblings Evaluate the likelihood of disease progression Diagnosis To determine if the condition is idiopathic, syndromic, congenital, or neuromuscular, specific questions should be asked: - Does the patient have any neurological problems? - Are there structural differences compared to siblings? - How was the patient born? Were there any complications during birth? Family History Gathering a family history is essential to identify any other potential cases. Assessing Progression The most critical factor in assessing the likelihood of progression is the patient's age and growth potential. If the spine has stopped growing, changes in curvature are unlikely to occur or will be minimal. Key questions include: - For female patients, when and if they started menstruating? - For male patients, when and if puberty begin (e.g., development of axillary hair)? This information helps determine the patient's developmental stage, as significant growth spurts typically occur during puberty. Notably, females usually experience a growth spurt before menarche, so if menstruation has already started, it's likely that the growth spurt has occurred. Additionally, inquire if the patient has experienced a growth spurt in the past 1 to 6 months. Discovery of Spinal Curve It's important to ask how and when the spinal curve was first noticed: - Did the patient discover it while looking in the mirror? - Did a parent notice it? - Did a friend see it while swimming? - Was it identified by a coach in the gym? - Was it discovered by a doctor during an examination or through X-rays? - When was it first noticed? Changes Over Time Inquire if the patient feels that the condition has worsened since it was first noticed: - When looking in the mirror, does the patient notice any asymmetry, such as one hip being more elevated than the other? - Does the patient observe any deviation of the umbilicus to one side? This comprehensive history will aid in diagnosing the condition and understanding its implications for the patient’s health and development. When evaluating a patient with scoliosis, it's important to follow a systematic clinical examination to assess the condition and rule out other potential causes (all the tests in the next slide should be preformed on the patient) Postural Assessment: - Ask the patient to stand up straight, and observe from both the front and back. - **Truncal Shift**: Determine if the head is aligned above the sacrum. If not, check for a right or left shift in the trunk. - **Shoulder Height**: Look for asymmetry in shoulder height to determine if one shoulder is higher than the other. - **Rib Rotational Deformity**: Check for rib prominence or rotational deformity, particularly using the Adam’s forward bend test (explained later). This can reveal rotational abnormalities in the ribs, which are common in scoliosis. Rule Out Other Causes: - Examine the patient for any signs that could suggest other underlying conditions, such as: - **Meningocele** or other congenital deformities. - **Spinal Dysraphism**: Look for midline skin defects, including: - Hairy patches - Dimples - Nevi (pigmented spots) Neurological Examination: - End the physical examination with a comprehensive neurological exam. - **Reflexes**: Pay particular attention to reflexes, ensuring they are symmetrical For example, test the abdominal reflex: - Have the patient lie supine. - Scratch diagonally superior to the umbilicus. - Observe if the umbilicus moves in response and compare this to the other side. If absent symmetrically, it is stil non-pathological, but asymmetry suggest a neurological issue.  Allergy CLINICAL ASSESSMENT Px Ask the patient to stand and look for: Truncal shift Shoulder height & Rib rotational deformity (rib prominence) Adam test Waist asymmetry and pelvic tilt Leg length inequality Foot deformities (cavovarus) Signs of spinal dysraphism (midline skin defects; hairy patches, dimples, nevi) Cafe-au-lait spots (neurofibromatosis) Asymmetric abdominal reflexes Adams forward bending test Dr Osama Aldahamsheh No truncal shift observed (the head is aligned above the sacrum). The left shoulder is higher than the right. There is a curve to the right. The iliac crests reveal asymmetry; the fold between the thoracic cage and the iliac CLINICAL ASSESSMENT crest on the right side is higher and more ↳ prominent. wine wat a · An X-ray shows a curve to the right, Adam's test is performed by asking the patient to bend forward, while keeping the knees straight and arms extended downward. You stand behind the patient to observe any imbalance in the thoracic cage. A positive sign is referred to as a "rib hump," which indicates rotational deformity. This can be indicating a structural deformity (the measured using a scoliometer to assess the degree of spinal heart is located on the left side). rotation. Since scoliosis is a 3-dimensional deformity, when the Dr Osama Aldahamsheh spine rotates, it pulls the thoracic cage along with it.  CLINICAL ASSESSMENT These photos represent spinal dysraphism indicating congenital abnormality (a) Vestigial tail formation (b) Cutaneous hemangioma, (c) Subcutaneous lipoma (d) Hypertrichosis (e) Pathologic sacral dimple. Dr Osama Aldahamsheh  RADIOLOGICAL ASSESSMENT The difference between AP (anterior-posterior) and PA (posterior-anterior) X-rays XR Long film PA / Lat - depends on the direction from which the X-ray beam passes through the patient: - **AP (Anterior-Posterior)**: The X-ray beam enters from the front of the patient. Bone Maturity - **PA (Posterior-Anterior)**: The X-ray beam enters from the back of the patient. MRI For scoliosis patients, PA X-rays are preferred over AP X-rays. To Reduced Radiation Exposure: Since scoliosis patients, who are often female, require frequent X-rays (every 1 to 6 months), using PA X-rays helps minimize radiation exposure to breast in females (continuous x-ray can increase cancer risk) In radiological assessment: 1 First, assess the degree of scoliosis to determine its severity (by X-ray) 2 Determine the patient's bone age to predict progression. 3 Consider MRI, although it's not necessary for all scoliosis patients. Dr Osama Aldahamsheh  AV and EV The end vertebrae (E) are those most tilted The apex (A) is the disk or vertebra deviated farthest from the center of the vertebral column. Apex vertebra is the most rotated one To measure the Cobb angle Identify the Vertebrae: Locate the most tilted vertebrae at the top (proximal ) and bottom (distal) of the scoliotic curve. extend lines from the vertebrae borders For upper end vertebrae take the line from the upper end plate For lower end vertebrae take the line from the lower end plate where the intersection happens measure the Cobb angle The apex is the furthest vertebra from the midline This is scoliosis to the right With a Cobb angle of 65 degrees Apex at T9-T10 disk Upper vertebra is T6 Lower vertebra is L1 Dr Osama Aldahamsheh  RADIOLOGICAL ASSESSMENT * * Left side scoliosis With apex at the disk between T12 and L1 With Cobb angle of 70 Upper vertebra is T9 Lower vertebra is L4 Dr Osama Aldahamsheh  ↳ INDICATIONS FOR MRI G Male or left sided thoracic sclerosis or abnormal reflexes (most important) 1. Early age at onset 2. Rapid Progression 3. Left sided curve 4. Severe curve Scoliosis is typically painless by default; however, 5. Back pain pain may arise after exercise or prolonged sitting. This pain originates from the muscles, which become overworked in their efforts to maintain spinal balance. 6. Neurologic symptoms 7. Weakness or spasticity on exam Los Or hyperreflexia 8. Asymmetric reflexes 9. Cutaneous lesions 10. Cavovarus feet Deformity in foot Dr Osama Aldahamsheh  BONE MATURITY 1. Tanner staging 2. Left Hand X-ray Sander 3. Risser Score 4. Menarchal status 5. Shaving status Dr Osama Aldahamsheh Identifying bone Maturity The Risser score is based on the ossification of the iliac crest, which occurs at the secondary ossification center of the pelvis. During growth, this secondary ossification center gradually ossifies (calcium deposits) (beginning anterior and ending posteriorly), signaling the end of skeletal growth. 1. Risser 0 :No ossification yet at the iliac crest. The secondary ossification center has not begun forming bone, indicating early stages of growth, with a high risk of scoliosis progression. 2. Risser 1: The secondary ossification center starts forming bone, with up to 25% ossification of the iliac crest. The growth spurt is underway, and scoliosis can still progress. 3. Risser 2: 26–50% ossification of the iliac crest, indicating continued growth. This stage reflects ongoing fusion at the secondary ossification center, though scoliosis progression slows. 4. Risser 3: 51–75% ossification. The ossification from the secondary center is progressing towards completion. Growth is tapering off, and scoliosis progression is less likely. 5. Risser 4: 76–100% ossification. The secondary ossification center is nearly fused, with minimal growth remaining and reduced scoliosis risk. 6. Risser 5: Complete ossification and fusion of the iliac crest, marking full skeletal maturity. The secondary ossification center is fully fused, and scoliosis progression is highly unlikely. The Risser score is a valuable tool for assessing skeletal maturity and predicting scoliosis progression by evaluating ossification at the secondary ossification center of the iliac crest. This assessment helps determine how much growth potential remains in the spine. If a patient is diagnosed with scoliosis and has a Risser score of 0 or 1 (indicating immature bone), there are non-surgical treatment options available. However, it's important to note that the iliac crest's predictive value ( Risser ) for spine growth is not as reliable as the Sanders classification, Sanders classification evaluates the hand joint maturity using seven stages It focuses on the development of the bones in the hand and wrist, specifically the epiphyses (growth plates) This classification provides a more accurate assessment of skeletal maturity and helps guide treatment decisions for scoliosis management.  RISSER SCORE Dr Osama Aldahamsheh  NATURAL HISTORY 3 Progression depends on bone growth and the degree of the curve. A larger curve increases the likelihood of progression. Younger patients with immature bones and a lower Risser grade also have a higher chance # of curve progression. % % I Periods of spine growth spurts 1. 6 - 24 months Periods 2. 5 - 8ofyears spine growth spurts: 3. 11 - 14 years => greatest The growth 1. 6 Females - 24 stop months growing at 14 years old Males stop growing at 16 years old Dr Osama Aldahamsheh  Treatment Aim of treatment: reduce progression and fix the scoliosis 2 factors that affect progression: age and degree TREATMENT Observation for curve It was found that (immature bone) patient with less than 25° curve, the curve will not progress with time 50° Because with studies it was found that patients with 50 degrees curvature, the degree it will increase one degree per year (continuous fast progression) Dr Osama Aldahamsheh For a curve measuring 25–45°, there are two options: either to take no action or to use a brace. The decision depends on the patient’s age and the amount of remaining growth. If there is growth remaining, then bracing is recommended. The brace works by applying pressure to the spine at the apex and both ends of the curve, creating a three-point pressure system. This system aims to prevent growth on the convex side of the curve while allowing continued growth on the concave side. It’s important to note that if there is no growth remaining, the brace will not be effective, and no treatment is needed, since the curve will not progress. The primary goal of the brace is to prevent the progression of the curvature; it does not aim to reduce the angle but to maintain it at its current degree. The recommended duration for wearing the brace is crucial for its effectiveness. A study found that the effect of the brace begins at the 11-hour mark, with maximum effectiveness reached at 16 hours. Beyond this point, the effect plateaus. However, wearing the brace for 16 hours can lead to psychological trauma in some patients. Another study explored the option of wearing the brace only at night. It showed that patients who wore the brace for more than 16 hours a day had a 73% success rate, while the night-only brace produced competitive results. Both options are valid and can be considered for the patient based on individual needs and circumstances. Surgery is also an option for this group Since scoliosis patients tend to be females the patient may be concerned with cosmetic You need to sit with the patient and understand what they want and expect from treatment, to pick the best option  UNTREATED PROGRESSIVE SCOLIOSIS Cardiopulmonary failure Since the curve reduce the available space for the lungs and cardiac Degenerative changes of the spine Pain Cosmetic deformity Spinal imbalance Dr Osama Aldahamsheh  OVERVIEW Prevalence 1–4% Curve has a sharper angle over a shorter segment and is more resistant to conservative treatment than idiopathic curves Causes Spontaneous (most common) In utero exposure (alcohol, valproate, diabetes) Genetic Dr Osama Aldahamsheh ⑮ ASSOCIATED CONDITIONS (61%) Cardiac defects (20%), Order an echocardiogram to see the structure and function of the heart Genitourinary defects (20%) Order an ultrasound Spinal cord malformations (21–37%) (diastematomyelia or tethered cord) ↳ This is why MRI is ordered VACTERL syndrome Vertebral / Anal atresia/Cardiac / TracheoEsophageal / Renal / Limb abnormalities Klippel-Feil syndrome ****If a child was confirmed to have congenital sclerosis by X-ray you need to look for the associated symptoms Alagille syndrome Order an MRI, ultrasound and echocardiogram, send them for cardiology and nephrology specialist Dr Osama Aldahamsheh  PATHOGENESIS B Best type with least progression & atboth ata Worst type most progressive & Dr Osama Aldahamsheh The pathogenesis of congenital scoliosis involves problems in either vertebral segmentation or formation. In segmentation defects, one vertebra fails to fully separate from another, resulting in two possibilities: if the vertebrae remain completely attached, it's called a block vertebra; if they are partially attached, it is referred to as a bar. Formation defects occur when part or all of a vertebra does not develop properly. For example, if half of a vertebra fails to form, but the discs above and below are present, it creates a condition called hemivertebra. There are different types of hemivertebra based on the degree and location of the defect. Sometimes, segmentation and formation defects are combined, resulting in a mixed presentation. The most severe combination is (unilateral bar with hemivertebra) when there is a bar (failure of segmentation) on one side and hemivertebra (failure of formation) on the other side. This creates an imbalance where one side of the spine grows while the other remains fixed, leading to severe scoliosis. The least problematic defect is a block vertebra, where there is no movement between vertebrae, reducing the risk of progression. Extra note: The spine's embryology begins with the notochord, which acts as a framework for spinal development. Mesodermal cells form somites that segment into structures like the sclerotome, which eventually becomes the vertebrae. Proper segmentation of somites ensures the correct alignment of vertebrae, and abnormalities in this process can lead to congenital spinal deformities like scoliosis.  Ivestigation To rule out associated pathology Renal US Echo Radiology XR CT MRI Dr Osama Aldahamsheh  TREATMENT Observation of curve For block vertebra Small curve For small hemivertebra and very small curve Bracing is usually not effective Usually not effective. Can be used but not as primary treatment only used as temporary option to slow the progression until surgery is preformed It will fail if used as primary treatment (as time pass) Surgical treatment Fusion or removal of the hemivertebra Curve progression Onset of neurological deficit Decreased pulmonary functions Dr Osama Aldahamsheh  Kyphosis Kyphosis is a 1 plane deformity (on the sagital view) Normal kyphosis of thoracic spine 20-40 ( can reach 60 depending on the patient) Measuring the cobb angle of the lateral view (sagital plane) Dr Osama Aldahamsheh  CAUSES Scheuermann`s Kyphosis Postural round back Congenital kyphosis Syndromic spine deformity Dr Osama Aldahamsheh  Scheuermann`s Kyphosis Idiopathic Definition Rigid kyphosis is when Kyphosis is Rigid kyphosis present even if the patient is supine O Anterior wedging of >5 degrees Should be less then 5 to be normal across three consecutive vertebrae O Most commonly in the thoracic spine. Dr Osama Aldahamsheh  Scheuermann`s Kyphosis Incidence 0.4% to 8.3% most common type of structural kyphosis in adolescents typical age of onset is from 10-12 years age with small subset adult onset Demographics M:F ratio between 2:1 and 7:1 Anatomic location Usually in thoracic spine Dr Osama Aldahamsheh Less common form occurs in thoracolumber/lumber region (rare)  usually in thoracic spine Scheuermann`s Kyphosis Diagnosis Standard lateral XR - The measure of the wedging angle Hyperextension lateral XR. - To know if it is rigid or not To measure kyphosis on a lateral view X-ray, the Cobb angle is taken from the upper end vertebra (usually T1, although it can be difficult to see due to the shoulder and scapula) to the lower end vertebra (typically T12). A normal kyphosis Cobb angle ranges from 20 to 40 degrees. Any angle greater than this indicates abnormal kyphosis. Dr Osama Aldahamsheh Dr Osama Aldahamsheh  Scheuermann`s Kyphosis Presentation: asymptomatic, cosmetic, pain Treatment Physiotherapy Observation and PT Surgical management Indication Dr. Osama uses a threshold of more than 80 degrees in his clinic Severity of kyphosis > 70 And only preforms the surgery after the patient had give physiotherapy a try and the patient is still in sever pain. Presence of neurological deficits, and/or Persistent and progressive pain. Dr Osama Aldahamsheh