scoliosis

1. HOD:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSC (HON)
MODERATOR:DR.A.E.MANOHARAN
PRESENTOR:DR.THOUSEEF.A.MAJEED
Scoliosis

2. INTRODUCTION
• “Scoliosis” - Greek word meaning “crooked.”
• It is a lateral curvature of the spine in upright
position.
• The Scoliosis Research Society has defined scoliosis
as a lateral curvature of the spine greater than 10
degrees as measured using the Cobb method on a
standing radiograph.

3. • Triplanar deformity of lordosis,
rotation & lateral wedging of
vertebrae.
• It produces body disfigurement.
• When deformity is extreme it
compresses viscera and reduces
life expectancy of the patient.

4. Incidence of Scoliosis
• Develops between ages 8 to 15
(growth spurt)
• 7 times more prevalent in females
• 80% of scoliosis origin unknown

5. “Normal” alignment
• Spinous processes all line up in a
straight line over the sacrum
Scoliosis is a combination of
• Angular displacement
• Lateral displacement
Spinal Biomechanics

6. Lateral displacement • Angular displacement

7. Classification
• I. Non structural Scoliosis (Postural)
• II. Transient Structural Scoliosis
• III. Structural Scoliosis

8. I. Non structural Scoliosis
• Postural Scoliosis
• Compensatory Scoliosis
II. Transient Structural Scoliosis
• Sciatic Scoliosis
• Hysterical Scoliosis
• Inflamatory Scoliosis

9. III. Structural Scoliosis
• Idiopathic Scoliosis
 Old Classification
 Infantile Onset < 3 yrs Age
 Juvenile Onset 3-10 yrs Age
 Adolescent Onset > 10 yrs Age
 New Classification
– Early onset Onset < 8 yrs Age
– Late onset Onset > 8 yrs Age

11. • NEUROMUSCULAR DISORDER ASSOCIATED SCOLIOSIS
NEUROPATHIC
oPoliomyelitus
oCerebral palsy
oSyringomyelia
MYOPATHIC
oMuscular dystrophy
oUnilateral Amelia
oFriedreich’s ataxia

12. • TRAUMATIC SCOLIOSIS
o Vertebral
o Extra vertebral eg: Burns
eg: Fractures, irradiation Surgery

13. OTHER CAUSES OF SCOLIOSIS
• Neurofibramatosis
• Marfan’s syndrome
• Moroquio’s disease
• Arthrogryposis multiplex congenita
• Rheumatoid arthritis
• Stills disease
• Scheuermann’s disease
• Osteogenesis imperfecta
• Scoliosis assosiated with spinal tumours.

15. Physiological Effects of Scoliosis
• Mid-back pain
• lower back pain,
• neck pain, headaches,
• premature disc and joint degeneration
• Decreased pulmonary function

16. Descriptive terms
• The side towards which the convexity of the curve is
directed is designated as Right or Left.
• The involved location of the curve is described as
1. Cervial
2. Cervico thoracic
3. Thoracic
4. Thoracolumbar &
5. Lumbar

17. • Simple curve-Single spinal
deviation
• Compound curve-Displacements
in Right & Left direction
• Primary curve- Curve that
develops first
• Secondary or Compensatory
curve-Develops as a balancing
response to the primary curve

18. • Non structural curve- Curve
is flexible and corrects by bending
towards convex side
• Structural curve- Curve is not
corrected on bending on convex side
( vertebral and para-vertebral bodies
and soft tissues are deformation
developed)

19. • Major curve-Significant structural
changes take place (the one of greatest
degrees)
• Minor curve-Secondary or compensatory
curve in the opposite direction above and
below the major curve.
• Usually functional and nonstructural

20. • Double major curve: Two
balancing curve of equal
structural change and magnitude.
• Thoracic curve is major and the
lumbar curve is structural.
• Because the main thoracic curve
is always larger than the
thoracolumbar/lumbar curve.

21. – Function of curves
• Strength
• Flexibility

22. • Most commonly used classification
• Describes 5 specific types of thoracic curves
based upon coronal radiographs
• Recommended specific fusion levels depending
upon the curve type.
KING CLASSIFICATION

23. Type I - lumbar dominant (10%) - S-
shaped curve, Both thoracic and
lumbar curves cross midline, Lumbar
curve larger or more rigid
King classification

24. Type II - thoracic dominant
(33%) - S-shaped curve, Both
thoracic and lumbar curves
cross midline, Thoracic curve
larger or more rigid
King classification

25. Type III - thoracic (33%) -
Thoracic curve, Lumbar curve
does not cross midline
King classification

26. Type IV - long thoracic
(10%) - Long thoracic
curve, L5 over sacrum,
L4 tilted into curve
King classification

27. Type V - double thoracic (10%) -
Double thoracic curve, T1 tilted
into upper curve, Upper curve
structural
King classification

28. INFANTILE IDIOPATHIC SCOLIOSIS
• Younger than age of 3 years
• Boys > girls,
• Primarily thoracic and convex to the
left.
• One hip is prominent but no ribs to
accentuate deformity
• Associated with Mental deficiency,
Congenital dislocation of hip,
Congenital heart defects

29. • Self-limiting
• Spontaneously resolve (70% to 90%)
• Progressive -
– Compensatory or secondary curves develop,
– > 37 degrees by Cobb Method

30. JUVENILE IDIOPATHIC SCOLIOSIS
• Uncommon
• Between the ages of 4 and 10 years
• Right Thoracic curves
• 12% - 21% of idiopathic
• Prognosis is worse
• Surgical correction may be necessary before puberty

31. • Commonest type
• Age 10- 16 yrs
• Primary thoracic curve usually convex to right
• Lumbar curves to the left
• Intermediate (thoracolumbar) & combined (double
primary) curves also occur
• Curves under 20 degree either spontaneously or remain
unchanged
ADOLESCENT IDIOPATHIC SCOLIOSIS

32. ADOLESCENT IDIOPATHIC SCOLIOSIS
Proposed etiological factors,
(1) genetic factors,
(2) neurological disorders,
(3) hormonal and metabolic dysfunction,
(4) skeletal growth,
(5) biomechanical factors, and
(6) environmental and lifestyle factors.

33. • Once starts to progress, it goes
on throughout growth period
• Reliable predictors of
progression
1) Very young age
2) Marked curvature
3) Incomplete Risser sign at
presentation
ADOLESCENT IDIOPATHIC SCOLIOSIS

34. Problems in adult life
(1)Back pain,
(2)Pulmonary dysfunction,
(3)Psychosocial effects,
(4)Mortality

35. • Slightly more in females
• More common in right
• Features midway between
adolescent thoracic & lumbar
THORACOLUMBAR

36. • Common in females
• 80% convex to left
• One hip prominent
• Not noticed early
• Backache in adult life
LUMBAR SCOLIOSIS

37. • 2 primary curves, one in each
direction
• Radiologically severe
• Clinically less noticable
• Because always well balanced
COMBINED SCOLIOSIS

38. Structural scoliosis
• Non correctable deformity of affected spinal
segment.
• Vertebral rotation is an essential component.
• Spinous process swing round towards the
concavity of the curve.
• Transverse processes on the convexity rotates
posteriorly.

39. • In thoracic region the rib on the
convex side stand out predominantly
& produces rib hump.
• Initially deformity is corrected.
• When deformity is fully established
the deformity is liable to increase
through out the growth period.

40. Types of structural scoliosis
• Idiopathic scoliosis (no obvious cause).
• Congenital or Osteopathic.(bony abnormality).
• Neuropathic
• Myopathic
(Associated with muscle
dystrophies)

41. Congenital or Osteopathic
- Due to defect in segmentation or
defect in the formation including
- Hemivertebra
- Block vertebra
- Wedged vertebra
- Curves progress rapidly during
pre- adolescent growth period

42. CONGENITAL SCOLIOSIS

43. • Curve is long, convex towards the side with weaker
muscles ( spinal, abdominal or intercostal) & at first
mobile
• Loss of stability & balance which makes sitting
difficult in severe cases
• Loss of sensibility causes pressure ulceration
B.PARALYTIC SCOLIOSIS

44. • Deformity is usually the presenting symptom
• Pain is rare complaint
• Rib hump or abnormal para spinal muscular
prominence indicates spinal rotation
• Rib hump leads to asymmetry of trunk
called angle trunk rotation (ATR) .
CLINICAL FEATURES

46. • Trunk should be exposed
completely & examined in front ,
back & side
Trunk alignment
• Symmetry of shoulder girdles
• Scapula & ribcage observed for
asymmetry
• Spinous process palpated to
determine their alignment
CLINICAL EVALUATION

47. CLINICAL EVALUATION
• Plumb line - On posterior aspect, line drawn
from occiput should normally align with
gluteal cleft

48. SCOLIOMETRY
•The patient bends over, arms
dangling and palms pressed
together, until a curve is
observed in the back.
•The Scoliometer is placed on the
back and measures the apex (the
highest point) of the upper back
curve.
Bunnell Scoliometer

49. ADAM’S FORWARD BEND TEST
• Patient is asked to lean forward with feet together and bend 90
degrees at the waist.
• The examiner can easily view the angle & any asymmetry of the
trunk or any abnormal spinal curvatures.

50. • To determine the severity of the curve
• X-ray Antero Posterior, Lateral & Oblique view of
spine
• Right & left bending view – determine the degree
of flexibility of spine & to see how much curve can
be passively corrected
RADIOLOGY

51. X Ray Standing AP film of whole spine on one film.

52. Lateral flexion AP radiographs
• provide information on the upper
and lower limits of a fixed curve
• Mobility of the motion segments, as
an aid to fusion levels.

53. Radiographs are assessed for
• Spinal column contour
• Congenital or developmental abnormalities,
• Degenerative
• Neoplastic abnormalities

54. CURVE MEASUREMENTS
• COBBS METHOD
• RIB ANGLE OF MEHTA
• SCOLIOTIC INDEX
• RISSER-FERGUSON METHOD

55. • End-vertebrae -
maximum rotated
vertebra (most tilted
vertebrae )
• Apical vertebra-Vertebra
at the centre of the curve.

56. • Line drawn at end plate of
upper end vertebra
• Another line at lower border
of lower end vertebra
• Perpenidular lines are drawn
from above two lines
• Angle formed between them
measured
LIPPMAN-COBB METHOD

57. Double curve
• One vertebra is upper end
vertebra for lower curve and
lower end vertebra for upper
curve (transitional vertebra).
Only one line drawn on this
vertebra.

59. The difference between the
angle formed by a vertical line
through the centre of the
apical vertebral body on an AP
film and the rib on the convex
side and the same angle on the
concave side.
RIB ANGLE OF MEHTA

60. More than 200 or overlap of the head of the
rib over the vertebra are associated with a
high likelihood of progression.

61. •Each vertebra (a–g) is considered an
integral part of the curve.
•A vertical spinal line (xy) is first
drawn whose endpoints are the
centres of the upper and lower end-
vertebrae of the curve.
SCOLIOTIC INDEX

62. •Lines are then drawn from the centre of
each vertebral body perpendicular to the
vertical spinal line (aa', bb', … gg').
•The values yielded by these lines
represent the linear deviation of each
vertebra
•Sum of vertebral body lines, divided by
the length of the vertical line (xy) gives
the scoliotic index

63. RISSER-FERGUSON METHOD
•First line originating at the centre of
the upper end-vertebra
•Second line from the center of the
lower end-vertebra.
•Angle formed by the intersection of
two lines at the centre of the apical
vertebra gives the degree of curvature

64. • Rotation – reflects the degree of structural change
& resistance to correction of the scoliotic curve
• 2 methods are used.
• Moe pedicle method
• Cobb spinous-process method.
DEGREE OF ROTATION

65. • When the vertebra rotates, one pedicle moves
toward the midline
• It is the relationship to midline that determines the
degree of rotation
• Other pedicle moves towards the lateral border of
vertebral body
Displacement of Pedicles

66. Moe pedicle method
• Divides the vertebra into six equal parts.
• Normally, the pedicles appear in the outer parts

67. COBB SPINOUS-PROCESS METHOD
• Vertebra is divided into six equal parts.
• Normally, the spinous process appears at the center.
• Its migration to certain points toward the convexity of the
curve marks the degree of rotation.

68. • Secondary sex characteristics
• Bone age
• Excursion of iliac apophysis (Risser's staging)
• Ossification of the vertebral ring apophysis.
DETERMINING MATURATION

69. Ossification of the vertebral ring apophysis

70. Excursion of iliac apophysis
• Ossification of iliac crest starts laterally & proceeds
medially toward sacrum.
• Maturation complete, when it reaches Sacroiliac junction

71. Risser's staging
Based on iliac crest
apophysis ossification
• Type I – ossification of
lateral 25%
• Type II – lateral 50%
• Type III – lateral 75%
• Type IV – lateral 100%
• Type V – fusion of Ilium

72. CT scans are used to provide
improved definition of
abnormalities of vertebral
size, shape or number

73. Magnetic resonance
imaging - to evaluate the
spinal cord and spinal
nerves.
Myelography

74. Other Studies
Pulmonary function
testing for patients with:
Curves greater than 60
degrees
Respiratory complaints
Scoliosis resulting from
a neuromuscular cause

75. TREATMENT

76. Aims of treatment
1) To prevent progression of the deformity
2) To correct an existing deformity

77. Nonoperative treatment
• Observation
• Orthotics – braces
• Traction and Casting

78. Non operative
• Exercises maintain muscle tone but no effect
on the curve
• If curve between 20* & 30* is progressing,
bracing done
TREATMENT

79. Orthotics
• Hibbs and Risser – Turnbuckle cast
• Milwaukee brace ( CTLSO )– 1946
• Thoracolumbosacral othosis (TLSO’s) – 1960s

80. Milwaukee brace
• Pelvic girdle
• Uprights – one anterior
and two posterior.
• Cervical ring with throat
mold and occipital piece
• Lateral pad – pressure on
apical vertebra

81. Thoracolumbosacral othosis (TLSO’s)

82. Contra indictions for orthosis
• Curve > 40 °
• Extreme thoracic kyphosis
• Mature adolescent ; Risser grade 4 or 5, girls 2
yrs post menarchal
• High thoracic or cervicothoracic curves

83. • Daily application of longitudinal & lateral traction
forces mobilize the spine gradually
• Patient in lying position, head end attached with 10
pounds weight pulls proximally
• Pelvic girdle & traction straps with 20 to 30 pounds
weight pull distally
Stretching

84. Halo traction device
• Spinal skeletal traction &
fixation device
• Halo traction device attached
to skull & is connected to a
plaster body cast by a steel
frame

85. SURGERY
Criteria :-
1.Curve more then 40degree
2.Progressive increase in scoliosis
3.Failure to conservative treatment
4.Cardiopulmonary complications.

86. Methods :
1.Herrignton rod :- only fusion of spine
vertrebra , no correction of the deformity.
2.Double rod method : - on every single level
of vertebra of spine is fixed with screws.
3.Vertebral fusion :- fusion of vertebra where
scoliosis develop.

87. • A rod is applied posteriorly along
the concave side of the curve
• Movable hooks attached to rod
which are engaged in upper &
lowermost vertebra to distract the
curve
Harrington system

88. • If curve is flexible, it will passively correct &
bone grafts are applied to obtain fusion
Disadvantage
• Does not correct the rotational deformity at the
apex of the curve
• Rib prominence remains unchanged

89. • Modification of Harrington system
• Wires are passed under vertebral lamina at multiple
levels & fixed to rod on the concave side of the
curve
• Bending the rod & arranging the mechanism so that
wires pull backwards than side wards
• Rotational deformity is improved
ROD & SUBLAMINAR WIRING
(LUQUE)

90. • Posterior rod system with multiple hooks placed at
various levels to produce either distraction or
compression
• With double rods, one can distract on concave &
compress on convex side
• Rotational deformity corrected.
COTREL-DUBOUSSET SYSTEM

91. • Rigid curves & thora-columbar curves associated
with lumbar lordosis corrected from front.
• Removing the discs throughout the curve & then
applying a compression device in the convex of the
curve
• Bone grafts are added to achieve fusion
ANTERIOR INSTRUMENTATION (DWYER,
ZIELKE)

92. • Treated by applying serial elongation- derotation –
flexion(EDF) plaster casts
• Can be applied till 4yrs
• If deformity deteriorates, surgical correction done
• Anterior disc excision with use of rod to aid
correction
INFANTILE IDIOPATHIC SCOLIOSIS

93. Non operative treatment
• Milwaukee brace from age 1 or 2yrs until 9 or 10yrs when
surgery is done
• Previously, Risser localizer cast was used in children
from 1 to 4yrs
Indications
• progressive curve, moderately flexible
• Non progressive, somewhat flexible but unacceptable
CONGENITAL OR OSTEOPATHIC

94. PARALYTIC SCOLIOSIS
• Conservative---- fitting a suitable sitting
support.
• Surgery---- stabilisation of entire paralysed
segment by combined anterior & posterior
fusion.

95. CEREBRAL PALSY SCOLIOSIS
• Most often thoracolumbar curve
• Pelvic obliquity & hip contracture present
INDICATIONS
• Progressive curve of any degree
• Normal mortality

96. TREATMENT
• For severe lumbar & thoracolumbar curves anterior
fusion with dwyer instrumentation then after 2
weeks posterior fusion with harrington rods.

97. NEUROFIBROMATOSIS SCOLIOSIS
• Constitutes about 1%
• Associated with skin lesions , multiple neurofibroma
& bony dystrophy affecting vertebra & ribs
• Curve is short & sharp
• Mild cases – conservative
• Severe cases – combined anterior & posterior
fusion.

98. SUMMARY
• Curves <20’ needs observation.
• Curves more than 20 treatment.
• Curves between 20 to 40 degree can be treated
by bracing
• Curves > 40 degree needs surgical correction
& fusion.