Nur Adzyan Ruhaizad Scoliosis 543-15-16

8/17/2019 Nur Adzyan Ruhaizad Scoliosis 543-15-16

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PAEDS ORTHOPAEDIC

(SCOLIOSIS)

Nur Adzyan Ruhaizad1001335975


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LEARNING OUTCOMES

• Describe epidemiology, aetiology and pathoanatomy o scoliosis!

• Describe the clinical eatures o scoliosis!

• "elect rele#ant in#estigations to con$rm the diagnosis according tothe age o presentation and to monitor the progress o disease!

• %lan the management according to the state o disease and age othe patient!

• De#elop regular ollo& up plan and management!

• Discuss the complications o scoliosis and pre#ention by screening!


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• "coliosis is an apparent lateral'side&ays( cur#ature o the spine!

• )&o broad types o deormity are *

%osturalscoliosi

s

"tructuralscoliosi

s


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POSTURAL SCOLIOSIS

Deormity is secondary or compensatory to somecondition outside the spine + short leg, or pel#ic tilt due tocontracture o the hip!

hen patient sits 'thereore cancelling leg asymmetry(the cur#e disappears!

-ocal muscle spasm a.& prolapsed lumbar disc maycause a s/e& bac/+ although sometimes called sciaticscoliosis


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STRUCTURAL SCOLIOSIS

• 2n structural scoliosis there is a noncorrectabledeormity o the a4ected spinal segment, anessential component o &hich is #ertebral rotation!

• )he spinous processes s&ing round to&ards theconca#ity o the cur#e and the trans#erse processeson the con#eity rotate posteriorly!

• 2n the thoracic region the ribs on the con#e sidestand out prominently, producing the rib hump,&hich is a characteristic part o the o#erall deormity!


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TYPES

Idiopathic

scoliosis

Osteopathic(Co!eital)

Scoliosis

Ne"#opathic

ad$%opathicscoliosis

Scolios ade"#o&'#o$a

tosis


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CLINICAL EATURES

D86R2):

• 6b#ious s/e& bac/ orrib hump inthoracolumbar cur#es

• ;alanced cur#essometimes pass

unnoticed until an adultpresents &ith bac/ache

%A2N

• Rare complaint

• %ossibility o a neuraltumour and the needor R2

•

"coliosis &ith painsuggests a spinaltumour until pro#enother&ise

8A2-:


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)run/• ?ompletely eposed, eamine rom ront, bac/ and side

"/in• "/in pigmentation• ?ongenital anomalies * sacral dimples or hair tuts

"pine

• ay be ob#iously de#iated rom the midline• ay become apparent only &hen the patient bends or&ard

'Adams test(• -e#el and direction o the maor cur#e con#eity are noted


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Neurological

eamination

• Any abnormality suggesting a spinal cordlesion calls or ?).R2

-eg legth

• -ength is measured• 2 one side is short, pel#is is le#elled by

standing the patient on &ooden bloc/s andreeamined the spine

>eneraleaminati

on

• "earch or the possible cause• Assessment o cardiopulmonary unction

'reduced in se#ere cur#es(


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alacedde*o#$ities * theocciput is o#er the

midline

U'alaced (o#deco$pesated(

cur#es * the occiput isnot o#er the midline

Determined bydropping a plumbline

rom the prominentspinous process o ?7and noting &hether italls along the gluteal

clet


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• Diagnostic eature o $ed scoliosis is thator&ard bending ma/es the cur#e moreob#ious!

• "pinal mobility should be assessed ande4ect o lateral bending on the cur#e noted!

• "ideon posture should also be obser#ed! )here may appear to be ecessi#e /yphosisor lordosis


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IN+ESTIGATIONS

Plai ,-#a%s

S.eletal

$at"#it% /Risse#0s si!

CT 1 MRI * tode$ne a

#ertebralabnormality orcord

compressionP"l$oa#%

*"ctiotest * in se#erechest

deormity

ioche$ical

ade"#olo!icali2esti!atio

s


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PLAIN 3-RAYS

• 8ulllength posteroanterior '%A(

and lateral rays o the spine and

iliac crests must be ta/en &ith the

patient erect!

• )he degree o cur#ature is measured by dra&inglies o the ,-#a% at the "ppe# 'o#de# o* the

"ppe#$ost 2e#te'#a and the lo4e# 'o#de# o*the lo4e#$ost 2e#te'#a o* the c"#2e+ theangle subtended by these lines is the angle ofcurvature '?obbs angle(


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S5ELETAL MATURITY / RISSER0SSIGN

• 2liac apophyses start ossiying shortly aterpuberty + ossi&catio e,teds $ediall% ad6oce the iliac c#ests a#e co$pletel%ossi&ed6 *"#the# p#o!#essio o* the

scoliosis is $ii$al (Risse#0s si!)

• )his stage o de#elopment usually coincides &ithusion o the #ertebral ring apophyses!

• "/eletal age also may be estimated rom rayso the &rist and hand


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LATE-ONSET (ADOLESCENT)IDIOPATHIC SCOLIOSIS

• Aged 10 or o#er

• )his is the commonest type, occuring in 90 ocases

• ostly occur in girls

•

%rimary thoracic cur#es are con#e to the right,lumbar cur#es to the let+ intermediate'thoracolumbar( and combined 'double primary(cur#es also occur!


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• ost cur#es less than E0 degrees either resol#espontaneously or remain unchanged!

•

6nce cur#e starts to progress, it usually goes ondoing so throughout the remaining gro&thperiod!

•

Reliable predictors o progression are * – @ery young age

– ar/ed cur#ature

– 2ncomplete Rissers sign at presentation


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TREATMENT

• Aims o treatment * – )o pre#ent a mild deormity become

se#ere

– )o correct eisting deormity that isunacceptable to the patient

Nonoperati#etreatment

6perati#etreatment


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OPERATI+E TREATMENT

• "urgery is indicated * – ?ur#es o more than 30 degrees that are cosmetically

unacceptable, esp in prepubertal children &ho areliable to de#elop mar/ed progression during gro&th

spurt – ilder deormity that is deteriorating rapidly!

• 6becti#es are * –

)o halt progression o deormity – )o straighten the cur#e 'including the rotational

component(

– )o arthrodese the entire primary cur#e by bone grating


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OPERATI+E TREATMENT


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6%RA)2@ )RA)N)

• Rod &as applied posteriorly along the conca#e side o the cur#e+attached to the rod &ere mo#eable hoo/s that &ere enggaged in theuppermost and lo&ermost #ertebrae to distract the cur#e!

•

Does not correct the rotational deormity at the ape o the cur#e thusrib prominence remains #irtually unchanged!


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• )his mechanism combines a pedicle scre& bo oundation at thecaudal end o the deormity, &ith multiple hoo/s &hich can beplaced a #arious le#els to produce either distraction orcompression!

• ?an correct the rotational deormity• "uJciently rigid to ma/e postoperati#e bracing unnecessary

?otrel FDubousset

system

• Rigid cur#es and thoracolumbar cur#es a.& lumbar lordosis

can be corrected by approaching the spine rom the ront,remo#ing the discs throughout the cur#e and then applying acompression de#ice along the con#e side o the cur#e!

• %ro#ides strong $ation &ith e&er #ertebral segments ha#ingto be used

• 6#eral shortening o deormed section lessens ris/ o cord

inury due to spinal distraction

Anteriorinstrumentation 'D&yer+

Hiel/e+Ianeda(


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7ARNING8

• hate#er method is used, spinal cord unction should bemonitored during the operation!

• 2deally this is done by $eas"#i! so$atoseso#% and $oto#e2o.ed potetials during spinal correction!

• 2 these acilities are not a#ailable, the 4a.e-"p test is used*anaesthesia is reduced to bring the patient to a semia&a/estate and he or she is then instructed to mo#e their eet!

• 2 there a#e si!s o* co#d co$p#o$ise6 theist#"$etatio is #ela,ed o# #e$o2ed ad #eapplied4ith a lesse# de!#ee o* co##ectio! %atients ha#e no memoryo the &a/eup procedure!


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COMPLICATIONS OSURGERY

• Neurological compromise

• "pinal decompensation

• %seudoarthrosis

• 2mplant ailure


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EARLY-ONSET (9U+ENILE)IDIOPATHIC SCOLIOSIS

• %resenting in children a!ed :/;, this type is"co$$o!

• )he characteristics o this group are similar

to those o the adolescent group, but thep#o!osis is 4o#se and surgical correctionmay be necessary beore puberty!

•


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EARLY-ONSET (INANTILE)IDIOPATHIC SCOLIOSIS

• ?hildren aged 3 or under, is rare in North America and isbecoming uncommon else&here

• ;oys predominate

• ost cur#es are thoracic &ith con#eity to the let!

• Although 90 o inantile cur#es resol#e spontaneously,progressi#e cur#es can become #ery se#ere+ those in &hich therib#ertebra angle at the ape o the cur#e di4ers on the t&o

sides by more than E0 degrees are li/ely to deteriorate

• ;ecause this also inKuences the de#elopment o the lungs, thereis a high incidence o cardiopulmonary dysunction!


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• ?ur#es assessed as being potentially progressi#e should betreated by applying se#ial elo!atiode#otatio-


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OSTEOPATHIC (CONGENITAL)SCOLIOSIS

• ?ommonest bony cause is some type o #ertebralanomaly

–


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• )hese children reGuire painsta/ing clinicalin#estigation and imaging – in order to disco#er any other congenital anomalies+

– to assess the ris/ o spinal cord damage!

)reatment * – )reatment is more diJcult and specialized than that o

idiopathic inantile scoliosis

– )hese children should be t#eated i special "its* the

approach is to "de#ta.e sta!ed #esectio o* thec"#2e ape,6 *ollo4ed '% ist#"$etatio ad spial*"sio!

– 2 multiple segments o the spine are in#ol#ed, surgery maybe too hazardous and should probably be &ithheld!


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NEUROPATHIC AND MYOPATHICSCOLIOSIS

• Neuromuscular conditions associated &ith scoliosis includepolio$%elitis6 ce#e'#al pals%6 s%#i!o$%elia6 #ied#eich0s ata,ia and the rarer lo&er motor neuron disorders and muscle dystrophies+ thecur#e may ta/e some years to de#elop!

• )he typical paralytic cur#e is lo!6 co2e, to4a#ds the side 4ith4ea.e# $"scles 'spinal, abdominal or intercostal(, and at $rst is mobile!

• 2n se#ere cases the greatest problem is loss o* sta'ilit% ad 'alace,&hich may ma/e e#en sitti! di=c"lt o# i$possi'le!

• Additional problems are !ee#ali>ed $"scle 4ea.ess and 'in somecases( loss o* sesi'ilit% &ith the attendant ris/ o pressure ulceration!

• Mray &ith traction applied sho&s the etent to &hich the deormity iscorrectable!


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• )reatment depends upon the degree o

unctional disability *

• Mild c"#2es may reGuire no treatmentat all!

• Mode#ate c"#2es &ith spinal stabilityare managed as or idiopathic scoliosis!

• Se2e#e c"#2es, associated &ith pel#icobliGuity and loss o sitting balance,can oten be managed by $tting asuitable sitting support!

• 2 this does not suJce, operati#etreatment may be indicated! )hisin#ol#es stabilization o the entireparalyzed segment by combinedanterior and posterior instrumentation

and usion!

)ypical postpoliomyelitis paralyticscoliosis sho&n characterised by a

long ?shaped cur#e!


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SCOLIOSIS ANDNEUROIROMATOSIS

• About one third o patients &ith neuro$bromatosis de#elop spinaldeormity, the se#erity o &hich #aries rom #ery mild 'and notreGuiring any orm o treatment( to the most mar/ed maniestationsaccompanied by s/in lesions, multiple neuro$bromata and bony

dystrophy a4ecting the #ertebrae and ribs!

• )he scoliotic cur#e is typically short and sharp! 6ther clues to thediagnosis lie in the appearance o the s/in lesions and any associateds/eletal abnormalities!

• ild cases are treated as or idiopathic scoliosis!

• ore se#ere deormities &ill usually need combined anterior andposterior instrumentation and usion! As &ith other orms o s/eletalneuro$bromatosis, grat dissolution and pseudarthrosis are not

uncommon!


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)his patient has a short structural cur#eplus multiple s/in lesions F eatures

suggesting neuro$bromatosis


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)


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"2NAR ARI "

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Nur Adzyan Ruhaizad Scoliosis 543-15-16