Orthopedics, Bone Deformity, Bone disorder, Vertebral disorder

1. Shyala Chand
Year 5

2. 
Introduction
 Scoliosis is defined as a
lateral deviation of the
normal vertical line of
the spine >10º
associated with rotation
of the vertebrae.
 Three-dimensional
deformity of the spine -
sagittal, frontal, and
coronal planes

3. 
 ~2% of children affected at some stage of life
 ~10% of affected patients will require corrective
surgery
 Occurs in 1-3% of population below the age of 16
years.
 0.1% have a curve greater than 40 degrees.
 Girls are more affected than boys.
 Those with a curve of more than 30 degrees are
generally girls, outnumbering boys by 10:1.
Statistics

4. 
Anatomy
 All bony elements are
altered
 Vertebra are wedge
shaped
 Poorly Developed
Concave side
 Pedicles rotated
 Discs are wedged as
well

5. 

6. 
• Genetic
 Strongly Familial
 11% incidence in first relatives of patients.
• Tissue deficiencies
 common on Marfan’s syndrome
• Growth abnormalities
 Asymmetrical vertebral growth
• Central nervous system alteration
 Different size cerebral cortices.
 Associated Syrinx, Low lying cord, Arnold Chiari Malformation
–Functional Spinal Cord Tethering
Etiology

7. 
• Structural
 involves both a lateral curvature and rotation of the
vertebrae.
• Non- structural
 The spine has a lateral curvature but there is no
structural abnormality in the spine.
 The curvature is in response to habit or a disease
process.
Clinical Types

8. 
Structural Scoliosis

9. 
 A reversible lateral curve of the spine that tends to be positional or
dynamic in nature.
 No structural or rotational changes in the alignment of the vertebrae.
 Disappears when the patient is supine or prone or sitting
 Correction of the lateral curve is possible by:
• Forward or side bending. This test is done to determine whether the curve
straightens out as the child bends forward and to identify a visible,
rotational deformity of the rib cage
• Positional changes and alignment of the pelvis or spine.
• Muscle contraction
• By correction of a leg-length discrepancy
Non-structural Scoliosis
(Postural/ Functional)

10. 

11. 
 Postural– This curvature is due to prolonged use of a
wrong posture. It resolves when the child is lies down.
 Compensatory – It is caused by leg-length discrepancy.
There is no rotation of the vertebrae and it usually goes
off on sitting.
 Sciatic This curve results from trying to avoid pain from
an irritated sciatic nerve
 Inflammatory: Here a curvature in the spine is caused by
an infective process such as an appendicitis. The body
curves in response to the disease or abdominal muscle
spasm.
 Hysterical – very rare and has an underlying
psychological component
Non-structural Scoliosis

12. 
Classification
 Cervical curve – apex between
C1 and C6
 Cervico-thoracic curve - apex
between C7 and T1
 Thoracic curve - apex between T2
and T11
 Thoraco-lumbar curve - apex
between T12 and L1
 Lumbar curve - apex between L2
and L4
 Lumbosacral curve - apex
between L5 and S1

13. 
King’s Classification
Double curve,
both curve
cross the
midline,
• Lumbar
curve larger ,
stiffer than the
thoracic curve
Double curve,
both cross the
midline
• Thoracic
curve larger,
stiffer than the
lumbar
curves.
Thoracic
curve
crosses
midline
and lumbar
curve does
not cross
midline
Long thoracic
curve in which
L5 is centered
over sacrum
but L4 tilts into
long thoracic
curve
Thoracic
curve and
T1 tilts to
upper
curve

14. 
Lenke Classification

15. 
• History
 First noted and progression
 Family history
 Affected sibling 7 times more frequent
 Affected parent 3 times more frequent
 Recent growth history
 Sexual maturity
 Pain
 ‘Fatigue pain’
 Post diagnostic pain
 ‘Severe pain’
Diagnosis

16. 
 Iliac crest height
 Leg length discrepancy
 Shoulder height
 Arm trunk space
 Scapular position
 Trunk shift
 Neuro exam /Muscle charting
 Generalized Features – Marfan’s
 Inspection of skin
 Café au lait spots
 Hair patch
Physical Examination

17. 
Adam’s Forward Bend
Test

18. 
 < 7 degrees is normal
Scoliometer

19. 
 Posteroanterior and lateral radiographs
 Right and left bending films, traction films, fulcrum
bending films, or push prone radiographs –
flexibility
 Stagnara - eliminate rotational component of the
curve.
 Radiographic parameters - to assess maturity.
Hand and wrist and development of the iliac apophysis
(Risser sign), triradiate cartilage, olecra- non apophysis
ossification, and digital ossification
Radiographic
Evaluation

20. 
Cobb’s Angle

21. 
 Nash & Moe
Vertebral Rotation

22. 
 Skeletal maturity
 Based on ossification of iliac apophysis
 Graded from 0 (no ossification) to 5 (complete bony
fusion)
Risser Grade

23. 
 Neurologic deficit
• Necessary in cases of:
 A thoracic curve to the left.
 Painful scoliosis.
 Abnormal neurological findings.
 Excessive stiffness.
 Deviation to one side during the bend test.
 Sudden rapid progression of a previously stable
curve.
MRI

24. 
 Curves 30 to 50 degrees progress an average of 10 to
15 degrees over a lifetime.
 Curves > 50 at maturity progress steadily at a rate of
1 degree per year.
 Curves less than 30 at bone maturity are unlikely to
progress.
 At 90 degrees or greater: increased potential for life
threatening effects on pulmonary function.
Progression

25. 
 Observation
 Bracing
 Surgery
Treatment

26. 

27. 
Bracing
 Orthotic braces - 74%
success rate at halting
progression
 Must be worn 20-23
hours a day, but most
pts are not compliant.
 Braces do not correct
scoliosis
• Contraindications
 Curves >450
 Patient with noticeable
Trunk shift
 Skeletally mature
adolescents – Riser 4-5,
2 yrs post menarchal
 Curve apex above T6
 Excessive Thoracic
Hypokyphosis < 200

28. 
MILWAUKEE BRACE Boston brace

29. 
 Spinal Fusion - motion segments (vertebrae) are
welded together using bone grafts, rod and screws.
• Posterior approach (back) – thoracic curves
• Anterior-posterior approach (front and back)
• Anterior approach (front) - thoracolumbar and
lumbar curves
• Thoracoscopic surgery (VATS, Video-Assisted
Thoracoscopic Surgery)
 Spinal instrumentation without fusion
Surgery

30. 

31. 

32. 
• Posterior approach
 required in patients with double or triple curves or
curves.

33. 
• Anterior-Posterior Approach
 performed in patients with
severe stiff curves and in young,
skeletally immature patients to
prevent crankshaft phenomenon.
• Crankshaft Phenomenon
 progression and rotation of
curve resulting due to growth of
anterior part of the spine and
fused posterior part.

34. 
• Anterior Approach
 thoracolumbar (thoracic-lumbar) and thoracic curves

35. 
• Growth Rods
 Commonly used in
children
 Allow for straightening
of the spine and
subsequent lengthening
procedures until the
patient reaches
adolescence when a
final fusion procedure
is performed.

36. 
THANK YOU