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Apparent lateral curvature of the spine Actually a triplanar deformity with lateral, AP and rotational component
Classification A Postural B Structural Idiopathic Infantile(birth to 3 years) Juvenile(4 to 9 years) Adolescent(10 to 20 years)
Classification cont. Congenital or osteopathic(bony anomalies) Neuromuscular Upper motor neuron cerebral palsy spinocerebellar degeneration Friedreich ataxia Charcot -marie -tooth diesease Roussy- levy Syringomyelia Spinal cord tumour/trauma
Classification cont. Lower motor neuron poliomyelitis other viral myelitis Spinal muscular atrophy Werdnig-Hoffmann Kugelberg-Welander Dysautonomia(Riley-Day syndrome) Myopathic Arthrogryposis Muscular dystrophy Congenital hypotonia/myotonic dystrophica Miscellaneous Connective tissue disorders/Neurofibromatosis
POSTURAL SCOLIOSIS
Deformity is secondary or compenstory to some condition outside the spine. Short leg, pelvic tilt or PIVD Disppears on flexion/sitting.
STRUCTURAL SCOLIOSIS
Non correctable deformity of the affected spinal segment The initial deformity is probably correctable, but once it exceed a certain point of mechanical stablity the spine buckles and rotates into a fixed deformity which does not disappear with change in posture.
CLINICAL FEATURES
Deformity is usually the presenting sympotm Backache Family history
Before 3 years of age, more frequent in boys primarily thoracic and convex to the left Etiology-multiple including genetic Positional factor-natural tendency of infant to turn right side during first fews months of life-gravity causes plastic deformity of thorax
In prone position,child can not roll onto its side, prevents asymmetrical moulding of vertebra
Progressive(increasing rapidly) or resolving spontaneously(in 70 to90%) Resolving type-before 1 years of age,smaller curve at presentation,no compensatory curves,curve with intrauterine positioning Progressive type-Development of secondary curves or curve more than37 degree at presentation. Rib vertebral angle(RVA)
Juvenile idiopathic scoliosis Between age of 4 to 10 years, more progressive than adolescent Specific factor for further evaluation are;a.pain b.rapid progression c.left thoracic deformity e.neurological abnormalities f.loss of bowel and bladder control.
Factors related to progression cont.. Girls>boys Define progression as increase 5 degree or more of cobbs angle over two or more visits. Premenarchal/adolescent growth spurt Reisser sign of 0(68% of Reisser sign 0 show progression while 18% those of 3 or 4) Double curve > single curve Thoracic curve> lumber curve More severe curves(Risk of progression for 20 degree curve is 20% that for 50 degree is 90%)
Major considerations in natural history of untreated adolescent idiopathic scoliosis Back pain( 77% in scoliosis as compared with 37% in control groups) location of pain variable, generally unrelated to the location or magnitude of the curve Pulmonary function- affected in thoracic curve,restrictive type of lung disese Psychosocial effects-many adult patients seeking treatment are concerned with cosmetic aspect of this disorder(Deformity)
Mortality-around 15%,related to thoracic curve > 100 degree, cor pulmonale Curve progression After skeletal maturity, cobb angle > 30 degree and apical vertebral rotation > 30 degree. Patient evaluation Through history,complete physical and neurological examination,height of patient both standing as well as sitting( change caused either by abnormality of lower extremities or spine itself) Neurological examination especially to rule out intraspinal tumours
Curve patterns: ponseti and friedman classification Single major lumba curve Single major thoracolumber curve Combined thoracic and lumber curve Single major thoracic curve Single major high thoracic curve Double major thoracic curve
King classification
Crankshaft phenomenon
Infantile Juvenile Adolescent Curve ;<1yr:90% 20% Rare Resolution; >1yr:20% Curve 60 to 90 deg 50 to 90deg >90 deg rare Magnitude; Orthotic effective at delaying Decreases the rate Effectively contrManagement; and slowing rate of progression until olscurves<40deg
progression puberty Ultimate proression100% Failure rate 30 to80% Success rate 75to80%
High
Low
Congenital scoliosis
Lateral curvature of the spine caused by the presence of vertebral anomalies that result in imbalance of longitudinal growth of the spine. Develop during first 6 week of intrauterine life Often rigid and difficult to correct, early detection and treatment is important Cause; believed to be nongenetic fetal environmental factors
Classification Failure of formation Partial failure of formation(wedge vertebra) Complete failure of formation(hemivertebra) Failure of segmentation Unilateral (unilateral segmented bar) Bilateral(Block vertebra)
Patient evaluation Routine spinal evaluation as well more specific physical findings s/b sought Skin of back;hair patches.lipomata, dimples and scars-underlying anomalous vertebra Neurological evaluation;club foot, calf atrophy,absent reflexes,atrophy of lower extremity Systemic involvement;genitourinary diseses 18%,congenital heart disese7%,diastematomyelia5%
Radiographic evaluation
Any evidence of widening of pedicles or midline bony defects Angle of curve measure by cobb method Tomogram further delineate the type of curve Myelography and MRI if diastematomyelia or neurological abnormality suspected MRI during infancy delineate the anatomical abnormality,may not visible on plain Xray Diagnostic ultrasound evaluation as well as excretory urography
Neuromuscular scoliosis
Contributing factors-loss of muscle strength or voluntary muscle control or loss of sensory abilities(proprioception) Younger age,larger percentage are progressive,continue to progress beyond skeletal maturity,curves long that include sacrum,pelvic obliquity is common,less tolerant of orthotic management Many cases require operative management that require longer fusion or fusion to pelvis
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