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- It is a 3D deformity of the spine in coronal, sagital and rotational planes. It is however defined as lateral curvature of spine of > 10 ° Cobb angle
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- Infantile < 3 year old
- Juvenile 4-10 years old
- Adolescent > 10 yo
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- Right thoracic curve
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- Based on the SRS criteria, depend on where Apex is
- T = T2-T11/12 disc
- TL = T12-L1
- L = L1/2 Disc to L4
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- Patient supine and relaxed
- Use an orange stick to stroke briskly but lightly in a medial direction acorss upper and lower quadrant of the abdomen
- Normal = contraction of underlying muscles with umbilicus moving laterally and up and down depending on the quadrant tested
- Looking for asymmetry
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- Girls - check at 11 yo primary 5 and secondary 2
- Boys - check only at secondary 2
- Consists of Adam's forward bending test with Scoliometer.
- > 5 ° ➔ do XR, Cobb > 10 ➔ refer specialist
idiopathic scoliosis in singapore schoolchildren.pdf867.1KB
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- There are three groups of criteria
- Disease Criteria (4)
- Disease must have significant impact
- Natural history of disease is known
- Detection can occur before a critical point before being too late
- There must be accepted and effective treatment available
- Screening test features (3)
- Accepted and tolerated
- High sensitivity - Low false negatives (can catch more - if there are low false negatives, then there has to be false positives)
- High specificity reduces false positive
- Population features
- Disease must have high enough prevalance [Scoliosis 3%, DDH 1:1000]
- Patients willing to undergo treatment
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- Stand with feet and knees together
- Bend down and watch for rub hump
- Looking for asymmetry and rib hump
- Scoliometer - 5-7 ° equivalent to 15-20 ° cobb angle
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- On the curve - Side of curve, offer to measure cobb angle at the end vertebrae (which are..), apex
- Red flag features - missing pedicles, widened pedicles (tumors), short sharp curves, pencilling bars and fused vertebrae
- Maturity - Look at iliac crest for Risser’s score (0-5)
- Ask to look for bending films (to assess structural) and sagittal films (to assess kyphotic component)
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- History – symptoms of a generalized syndrome or disorder (e.g. muscular dystrophy of neurofibromatosis), back pain, neurology such as weakness in any limbs, bowel or bladder symptoms. Juvenile < 10 years old
- Examination – asymmetrical reflexes, neurology, foot abnormalities, no rotational rib hump, atypical kyphosis
- Investigations – X-ray findings of atypical left-sided curve, acute angular curve, scalloping of vertebrae or pencilling of ribs.
- MRI features such as bone and spinal cord anomalies, syrinx, tumour or infection.
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- End vertebrae = most tilted from horizontal [used in measuring Cobb's angle]
- Stable vertebrae = most proximal vertebrae body that is bisected by Central Sacral Vertical Line [usually the most distal fixation]
- Neutral vertebrae = No rotation
- Apical Vertebrae = most deviated
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- Progression depends on remaining growth
- We can assess remaining growth clinically, radiologically
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- "Clinically and Radiologically"
- Purpose is to determine where the child is in relation to peak height velocity as a guide to know when the child can undergo bracing
- Puberty begins at a bone age of 11 in girls, and 13 in boys. Characterized by a rapid growth phase known as "peak height velocity"
- PHV reached in 2 years, Usually reaches skeletal maturity 2 years after menarche or Riser 1 (This would be the time to stop bracing)
- Clinical
- Menarche often occur at 13.5 years of bone age, usually when Risser 1, signals the beginning of the deceleration phaze
- PHV precendes menarche by a year
- Taner's staging - Stage 2 signals beginning of puberty
- Radiological
- Compare to Greulich -Pule atlas
- Sanders classification
- Stage 1 = all digital epiphysis not covered
- Sanders 3 = fusion of Middle phalanges = Risser 1
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- 1. Identify end vertebrae which is the level with greatest tilt from horizontal
- 2. Draw line from upper border and lower border respectively
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- Clinically - flexible curves normalizes when sitting down and pelvic leveled (due to pelvic oblquity), also normalizes on forward bend test
- On XR - Flexible curve normalizes with lateral bending
- Based on the Lenke classification, it is structural if it does not correct to less than 25° for coronal angles and 20 ° for kyphotic angles
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- Location of structural curve with 2 modifiers -
- presence of thoracic kyphosis (T5-T12) and
- Coronal alignment by the CSVL to lumbar apex
- In other words, 3 parts to the classificaiton - the number, the letter and the sagittal
- Number 1-6 = different configuration of structural vs non structural
- Letter A/B/C = Lumbar modifier
- Sagittal profile of T5-T12
- <10 (-hypo)
- 10-40 (normal)
- 40 (+ hyper)
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- Grade: neutral
- 1 - pedicle diseappearing
- 2 - no more pedicle
- 3 - Migrate to middle segment
- 4 = migrates past midlne
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- <25 = observe
- 25-40 = bracing based on SRS criteria
- > 40 = Surgery
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- This is a consideration for some surgeons
- Kevin Lim KKH - does routine MRI for all pre op even for AIS
- Ozturk et al. - 249 patients with idiopathic scoliosis. Routine MRI- 8% (20) has neural axis abnormalities - e.g. arnold chiari malformations, epidural lipoma
- 3 of them required surgical intervention for syringomyelia
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903144/#:~:text=In conclusion%2C magnetic resonance imaging,treatment of adolescent idiopathic scoliosis.
BRACING
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- 5 criteria
- 1. Magnitude - 25 - 40 °
- 2. > 10 year old
- 3. Risser 0-2 [Risser 1 coincides with menarche]
- 4. Pre-menarche or < 1 year postmenarchal. [Risser 1 coincides with menarche. So if we want Risser 0-2, then we can accomodate for Pre-menarche or < 1 year post menarchial]
- 5. No Prior treatment
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- Success of brace is time dependant
- Weinstein et al. NEJM 2013 – 12.9 hours a day a/w 90-93% success
- Multi-center study of 242 patients randomized into bracing or observation. Bracing group advised to wear 18 hours a day. Trial was stopped early due to the efficacy of bracing!
weinstein-effects-of-bracing.pdf587.3KB
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- 1. Success of brace is time dependant
- 2. Does NOT reverse but only halt progression!
- Can give a car analogy. Car is moving very fast and we are trying to put on the brakes. But even if we do that, there is a chance that it still can worsen
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- Check pressure points arm pits, sitting, standing
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- Lengthening must be achieved - level shoulders
- Cobb angle target - aiming for 50% correction of cobb angle
- 3 points fixation
- Rotational correction (Nashmoe classification)
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- Growth completed as seen from - Risser 4/ 5, 2 years post menarche
- OR when curve reach surgical magnitude of 40 degrees
SURGERY for AIS
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- Aims to prevent progression
- Correction is only partial nor full correction.
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- When curve > 45 degrees before skeletal maturity ➔ likely will progress
- When curve > 50 degrees at skeletal maturity ➔ will continue to progress
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- Proximally - difficult to determine. Some surgeons fuse to T2 if one shoulder is elevated
- Distally - fuse to stable vertebrae
- In adult scoliosis, fusion to sacrum improves correction and maintenance of saggital balance but increases risk
- Major curve must be addressed. By definition it is structural
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- Posterior instrumentation and fusion
- +/- Anterior instrumentation and fusion
- Indications - Large stiff curves > 75 deg, For very young patients to prevent crank shaft
- Transthoracic thoracoscopic assisted surgery (NUH) for single curves
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- Anterior - Vertebral body tethering (works by heuter volkman principle)
- Posterior - non fusion for AIS with ApiFix
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- Neurologic - paraplegia 1:1000
- Dural injury
- infection - Proprionibacterium acnes most common organism for delayed infection
- SMA syndrome [AKA Cast syndrome] - compression of 3rd part of duodenum due to compression between SMA and Aorta when spine is straightened ➔ intenstinal obstruction
- DVT, PE
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- Flat back syndrome - failure to restore lordosis or kyphosis leading to early fatigability and back pain
- Pseudoarthrosis/ non union
- Hardware failure
- Junctional failure
- Adjacent segment disease
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- Rotational deformity of spine created by continued Anterior spinal growth in setting of posterior spinal fusion
- Can occur in your patients when PSF is performed alone and anterior column is allowed continued growth
- Avoid by fusing anterior also
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- Instruments and implants
- Neuromonitoring
- Imagine intensifiers