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Laporan Pagi

SCOLIOSIS

Rochmanita Safitri
11/ KU/14786
Nama : Nn. VN
Usia : 34th
Jenis kel : Perempuan
Alamat : Wates
Tgl. Periksa : 13 June 2017
No. RM : 01.XX.XX.XX
Pemeriksaan : Thorax AP
Keluhan Utama :
Sesak dan nyeri punggung.
Hasil Foto Thorax
Tampak foto thorax dengan
proyeksi AP, posisi erek, kualitas
cukup.
Tampak opasitas homogen dg
batas tidak tegas pada kedua
pulmo yang mengaburkan
pembuluh darah, air bronkogram
(+)
Tampak zona lusen pada apex
pulmo dekstra.
Tak tampak pelebaran pleural
space.
Tampak diafragma dekstra licin
dan tak mendatar, diafragma
sinistra tak dapat dinilai
CRT : tidak dapat dinilai
Tampak VT melekuk ke kanan
Kesan :
suspect pneumothorax dextra,
besar cor tak dapat dinilai, dan
Hyperdextroscoliosis Thoracalis
SCOLIOSIS
Scoliosis
Abnormal lateral curvature of spine
in which there is deformity in the
coronal plane. Cobbs Angle >10
degree.
May alter sagittal plane as well
Thoracic kyphosis normally = 30-35
degrees
Range 10-50 degrees
Lumbar lordosis normally = 50-60
degrees
Range 35-80 degrees
Spinal rotation causes posterior
prominence
Upto 10 degrees is
normal.
Can be seen as C-
curve or S-curve.
S- curve is usually
compensatory.
Demographics :
Occurs in 2-3% 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.
Generally progresses during the period of
growth spurts.
Adolescents are more routinely tested for this.
Types of Scoliosis
Congenital

Neuromuscular
Cerebral palsy
Syndrome related
Marfans syndrome
Idiopathic

80% are this


Etiological Theories
Genetic
Tissue deficiencies
Growth abnormalities
Central nervous system alteration
Genetic
11% incidence in first relatives of patients
Normal incidence < 3%
Monozygote twins more common
No gene identified to date
Tissue Deficiencies
Marfans syndrome deficient fibrillin
Osteopenia noted in girls
Elevated calmodulin
Involved in contractile properties thru actin &
myosin
Elevated in platelets

No consistent findings to date


Growth Abnormality
Asymmetrical vertebral growth
Hueter-Volkman effect is suppression of growth on
concave side
Hypokyphosis during growth spurt
No increased incidence with growth hormone
No initiating factor identified
Classification
Infantile: 0-3 years old (.5%)
Juvenile: 4-11 years old (10.5%)
Adolescent: 10-17 years old (89%)
Adult: >18 years old
History
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
Physical Exam
Iliac crest height
Leg length discrepancy
Shoulder height
Arm trunk space
Scapular position
Trunk shift
Inspection of skin
Caf au lait spots
The Cobb Angle
Line across top of
cephalad and bottom of
caudad vertebrae that
are maximally displaced
Perpendiculars from
these two lines are
intersected
Angle between
perpendiculars = Cobb
Angle

http://www.pediatriceducation.org/2006/12/11/
Physical Examination:
Features suggestive of polio, neurofibromatosis,
Von Reclinghausen syndrome, Downs,
Marfans, Hurlers syndrome, neural tube defects
and osteogenesis imperfecta.
Forward protrusion of chest wall on affected
side.
Increased flank creases on opposite side.
Higher ASIS and PSIS on concave side.
Spinous process turned into concave side.
Tests of flexibility of spine:
Adams forward bending test.

Pushing the curve from convex side and noting


the correction.

Lifting the patient up from head.

Lateral bending.
Forward Bend Test
Adams sign
Early Detection:
Visual examination of
gait, posture, limb length
and lateral curvature of
spine.
A posterior view taken,
bent at 90 degrees at
hips.
Can also be detected
accidently when
radiographs are taken to
rule out other
pathologies.
Once scoliosis is suspected:
A scoliosis series is
ordered.
AP cervical, thoracic
and lumbar spine
Xrays collimated to
soft tissues needed.
Sometimes lateral
views may also be
necessary.
Imaging
Plain x-rays
Need standing 36 inch cassette
Posterior to anterior
Decrease thyroid and breast exposure 3-7 fold
Note rotation
Measure deformity by Cobb method
Skeletal maturity
Normal spine radiology
Cobb Method
Choose the most
tilted vertebrae above
and below the apex of
the curve.
Draw a line
perpendicular to that
vertebrae.
The angle created
between these
intersecting lines is
the Cobb angle.
Rotation
Spinous process rotates into concavity
Pedicle position
Risser sign due
to sceletal
maturity

Risser 1-5 digunakan untuk


mengukur maturitas tulang
dan memprediksi
progresivitas scoliosis
Insidensi progresi kurva
lebih tinggi pada Risser 1
daripada Risser 2 atau lebih
Who needs an MRI:
A thoracic curve to the left.
Painful scoliosis.
Abnormal neurological findings.
Untoward stiffness.
Deviation to one side during the bend test.
Sudden rapid progression of a previously stable
curve.
Will the curve progress?
Three factors involved in progression
patients gender
future growth potential
curve magnitude at time of diagnosis
Females are 10 times more likely to have
progression than males.
The greater the growth potential and larger
the curve = more likely to progress
Curve Progression
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.
Medical complications:
At 100 degrees or greater: increased potential
for life threatening effects on pulmonary
function.

Psychologic illness: seen in up to 19% of


females with curves great than 40 degrees as
adults.
Pulmonary Comorbidities
Restrictive lung pattern
Decrease in lung volumes
Vital capacity most significant
FRC, TLC, IC, ERV also

Impaired respiratory muscle function


Chest wall deformity = inspiratory muscles
working at mechanical disadvantage
Arterial hypoxemia from V/Q mismatch
Cardiac Comorbidities
Chronic hypoxemia HPV
Pulmonary Hypertension
RVH RV failure
MVP common among scoliosis patients
Scoliosis associated with congenital heart
disease (no specific lesion)
Treatment principles:
Orthotic braces - 74% success rate at halting
progression
Must be worn 20 hours a day, but most pts are
not compliant.
Braces do not correct scoliosis.
Surgical therapy is definitive, but indicated
only for those at 40 degrees or above
Infantile Treatment
Must prove idiopathic
90% are left thoracic
3 female : 2 male
90% resolve spontaneously
Predict progression by RVAD
< 20 degrees 83% resolve
>20 degrees 84% progress
Juvenile Treatment
Younger onset likely to progress

>30 degree curve almost always progress

Some adolescent curves are missed juvenile


Adolescent Treatment
Most curves <10 degrees
Boys = girls for these curves
Usually dont progress

More sever curves (>30 degrees)


8 girls : 1 boy
Predicting who will progress
Risk for Progression
Younger onset
Skeletal age
Risser 0-1 at presentation 60-70% progress
Risser 3 only 10% risk
Menses starts after growth spurt
Female more likely than male
Curve pattern
Apex above T12
Degree at presentation
20-29 degrees 68% risk for progression
30-59 degrees 90% risk for progression
Natural History
If curve <30 degrees at maturity
No adult consequences
Unlikely to ever progress

Curves >45 degrees may progress a degree/year


Mortality not increased unless curve >90 degree
Right heart failure
Decreased pulmonary function
Treatment : 10 degrees curve or
less
This curve is considered normal.
No action is taken.
Follow up appointments are prescribed to
monitor the patient.
Usually done every 3-6 months, but at the
physician discretion.
Treatment:10 to 25 degree curve
Sometimes no treatment needed, if no
progression.
Begins with simple orthotics(very effective)

daytime/nighttime braces.

Shoe lifts for leg length discrepancies.

Stretches, exercises.
Shoe Lifts:
Used for leg length
discrepancies.
Worn in regular
shoes.
Places opposing
pressure on scoliosis
curvatures.
Must be worn during
every scoliosis
radiograph.
Treatment: 25 to 35 degree curve
Day and night brace worn 20+ hours/day.

Shoe lifts may also be needed.

Stretches and exercises to loosen muscles and to


relieve pain if present.
Treatment: 45 degree + curve
Almost always treated with surgery.
Vertebrae are fused using-

Bone grafts.

Hardware(metal splints)

Still require braces to be worn in post op period.

Causes growth to stop.

Can cause nerve damage, infection and other


problems.
Left untreated:
If progressing, can worsen upto 70 degrees +
curve.

Places pressure on vital organs.

Can cause cardio-respiratory problems.

Can eventually become untreatable.


Non-Operative Treatment
<25 degrees monitor every 4-12 months
Depends on skeletal maturity
>25 degrees monitor every 3-6 months
>30 degrees in skeletally immature brace
Curve change by 10 degrees brace
Curve >40-45 degrees surgery
Braces :
Made of polypropylene.
Contoured to size and shape
of body.
Curved to oppose specific
points of scoliosis curvature.
Flexible and comfortable.
Worn under clothing.
Nighttime/daytime use.
Must be worn faithfully.
Examples of Braces Used in Scoliosis Treatment

Sponseller PD. J Pediatr Orthop 2011.


Bracing
Duration and time in brace
23 hours per day
Wear until skeletally mature

Types
Milwaukee
Underarm orthosis

Electrical stimulation
Braces
Successful Bracing
Prevent curve progression
Randomized study
Braced 74% did not progress
Not braced 34% did not progress

Electrical stimulation
33% did not progress
Charleston brace still controversial
Problems with Braces
Argued efficacy
Narrow treatment window to initiate
Poor compliance
Must have good orthotist
Curves corrected by 20 degrees in brace do better
Treatment Algorithm
Surgery
Failed bracing
Curves >45 degrees
Unbalanced curves >40
degrees
Surgery is fusion with
instrumentation
Surgical Options:
Infantile and juvenile scoliosis:
<8 yrs- instrumentation without fusion.

After 8 years- anterior and posterior spinal


fusion.

After 11 years- posterior spinal fusion.


Surgical Options:
Adolescent scoliosis:

Posterior spinal fusion with instrumentation.

Anterior spinal fusion if younger than 11 years


and with open triradiate cartilage.
THANK YOU

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