Scoliosis
Mr. Christopher I. Adams
Consultant Spinal Surgeon
Scottish National Spine Deformity Service
National Services Division
- “Spinal Surgery”
Year
Budget
£
Procedures
No.
2005 / 06
2,746,093
109
2006 / 07
2,912,821
145
2007 / 08
3,124,282
201
2008 / 09
?
213
2009 / 10
?
239
2010 / 11
4,910,000 (78%)
259 (137%)
www.nsd.scot.nhs.uk/publications/
OCAP & FRCS (Tr and Orth) / ST3-6
•
Applied Clinical Knowledge Syllabus
–
The Spine (Sec. 8-13)
•
–
Paediatric Orthopaedic Surgery (Sec. 8-14)
•
•
“Knowledge of the neurological processes
involved in the production of deformity e.g.
spina bifida, cerebral palsy and muscular
dystrophy”. Competence level 3 = “Knows
generally”.
Clinical Procedures Syllabus
–
Thoracic Spine – Scoliosis correction –
posterior (Sec. 8-24)
•
•
•
“A basic knowledge of the surgery of spinal
deformity and tumours of the spine”.
Competence level 3 = “Knows generally”.
Competence level 1 = “Has observed or
knows of”.
ST7-8, Competence level 3s = “Can manage
whole but may need assistance”.
Interrupt at any time for questions…if you
are thinking it, so are others.
Today’s Plan
•
•
•
•
•
Pathology
Measuring Scoliosis
Treating Scoliosis
Differences when not idiopathic
Congenital
• Handout
– All references
– Crib sheet
Classification
- Pathology
• Idiopathic (36%)
• Neuromuscular (21%)
– Duchenne = 15 patients
• Congenital (10%)
West of Scotland clinics = 414pts
• 2yr 10m, 26 Nov 2006 to 15 Sept 2009
Clinical Assessment
• History
–
–
–
–
deformity
pain
general health
development &
maturity
– family history
• Examination
– general (diagnosis)
– specific (deformity)
General Examination
• General appearances
– palate, ears, neck
• Skin
– hair patches, skin dimples
– scars
– café au lait patches
• Joint laxity
• Spinal dysraphism
– leg length, foot size inequality
– foot deformities
– asymmetric abdominal
reflexes
Examination of the Back
Quantifying Spinal Deformity
C7
T3
T5
T7
T9
T11
L1
L3
L4
Sacrum
Surface and Spine Measures
Bunnell WP.
JBJS [Am] 1984; 66-A: 1381-7.
Clinical and Surface Topography
Cobb Angle
θ
Outline for the Study of Scoliosis.
Cobb, John R. (New York, New York, U.S.A.)
American Academy Instructional Course Lectures
1948;Vol. 5: pg 266.
Classification - Type of curve - OLD
Classification - Type of curve
Lenke
Spinal Growth
Spinal Growth Velocity
Spinal Height
Gain (cm/yr)
Age
Risser Sign
GROWTH VELOCITY OF THE SPINE
98o
113o
3 months later
Scoliosis Progression
• Younger patients +
large curves = great
risk of progression
• Increased growth 
greater deformity
• Larger curves (> 50º)
 spontaneous
buckling
– Progression in
adulthood
130 cm
98o
The Spinal - Rib Cage Connection
Nash and Moe. A Study of Vertebral Rotation.
JBJS [Am] 1969; 51-A: 223-9.
Objectives of Surgery
• Cosmesis
– Prevention of curve progression
– Correction of curve
• Reduce the cardio-pulmonary
consequences of scoliosis
• Avoid neurological complications
Posterior Spinal Surgery
Case ♀ - AIS
66%
Pedicle Screw Constructs
- Idiopathic Scoliosis
15.11.2006
15yrs 1mth
08.03.2007
15yrs 5mth
58 o
23 o
45 o
23 o
Anterior Release & Costoplasty
Intra-operative Monitoring
- European Literature
• “Reviewing the literature
on intraoperative
monitoring makes it clear
that application of a single
method such as SEPs is
not sufficient and that
accounting for ascending
and descending pathways
of the spinal cord and
nerve roots requires a
multimodal approach.”
Current opinion and recommendations on multimodal IOM during
spine surgeries. With Spinal Osteotomy.
Sutter M, Delitis V, et al. (Multicentre)
Eur Spine J 2007;16 (Supp2): pg S232-7.
Intra-operative Monitoring
- Literature
Paper
Year
(pub)
Deformity
IOM +ve
Neurology
Bridwell
n= 500pt
1987-97
(1998)
Scoliosis
?
0.01% to
0.05%
SRS
n=670pt
2001-4
Kyphosis
?
0.4%
Vitale
n=151pt
1999-05
(2010)
Scoliosis
8%
1.3%
Lenke
n=42pt
2000-06
(2008)
Kyphosis
21%
2.4%
(recovered)
U.K.
N=~1400
?
?
?
?
Syrinx
•
•
•
•
Retrospective
1992 – 2005
n = 13
11 yrs 1 mth
– (3.6–16.4 years)
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia.
Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland)
Spine 2007;32 (21): pg 2327-33.
Syrinx
• All fusion
surgery
• No
neurological
deterioration
4vs= 4th ventriculo-arachnoid shunt
The Outcomes of Scoliosis Surgery in Patients with Syringomyelia.
Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland)
Spine 2007;32 (21): pg 2327-33.
Syrinx – Case ♀
• 13y10m
• Hx fall off
trampoline 2yrs
• Left mid thoracic
back pain, no
radiation.
• Neurology
– Symm. Absent
abdominal reflexes
Syrinx – Case ♀
Syrinx – Case ♀
Posterior decompression
by Miss Lynn Myles
16/09/2009
“Superior Mesenteric Artery Syndrome in
Paediatric Orthopaedic Patients”
• 1842 Rokitansky
• N = 14 pts
– 1979 to 1987
• Presentation
– Nausea
– Intemittent and large
bile-stained vomiting
– Between normal
appetite
– Bowel sounds
present
“SMA syndrome in paediatric ortho pts”
Hutchinson DT and Bassett GS.
from Ann Arbor, Michigan, USA
Clin Orth and Rel Research 1990 ;250:pg250-7.
Changing Practice - Spina Bifida
• Only 10%
no spinal
deformity
JBJS Br 1980; 62-B: p54-8
• 6 to 12
degrees
per yr
29.04.2008
2yrs 8mth
05.02.2008
17yr 2m
196
164
Spina Bifida - Case ♀
• 8y8m
• Pre-menarche
• Braced since
18mths
• Now tripod sitting
• Motor level L1
• VP shunt
• Vesicostomy
• PEG
• Painless right hip
dislocation
• Picture
no97
Spina Bifida - Case ♀
27.07.2007
no97
Spina Bifida - Case ♀
31.07.2007
8yrs 9mth
26.07.2007
8yrs 9mth
50 o
130 o
no97
Spina Bifida - Case ♀
Outcome
12.06.2007
8yrs 8m
11.12.2007
9yrs 2m
Brace
NO brace
no97
Surgical Objectives
• Preserve Neurology
– bowel and bladder
– sensation
– use of legs
• Spinal and pelvic alignment
– Level shoulders & pelvis
– CoG over sacrum
– Unaided sitting with stability
• Relationship to the hip
• Avoid other complications
Congenital
Congenital
“Congenital deformities of the spine”
McMaster MJ
J R Coll Surg Edinb 2002;47:p475-80
Congenital - Case ♂
Discussion / Comments / Questions
• …