Thoracic kyphosis - Sydney Adventist Hospital

Scoliosis, Kyphosis, lordosis in
Children
GP Symposium 2010
Andrew K Cree
MBBS(Hons) FRACS(Orth) FAOrthA
Director, Spine & Scoliosis Service
The Royal Alexandria Hospital for
Children, Westmead
Sydney, Australia
Spinal Surgery Fellowships
• Royal North Shore Hospital 1998
• University of Miami, Miami Children’s
Hospital Medical Centre 1999
Instructor Spinal Surgery,
Departments of Orthopaedics
& Neurosurgery,
University of Washington,
Seattle
1999-2000
• Director, Spine & Scoliosis Service CHW
• Director Spine Surgery Fellowship
Programmes RNSH & CHW
• VMO
– CHW, Westmead, RNSH
– SAN, Mater, North Shore Private, Westmead
Private
Appointments
• Westmead & Crows Nest Rooms (9687 6766)
• Outpatient Clinics
– Children’s Hospital Westmead (9845 2283)
– Royal North Shore Hospital (9926 8370)
Spinal Deformity in Children
Anatomical Planes
• Anatomical position
• Coronal (Frontal) divides the body into front
and back sections
• Sagittal - divides the
body into left and right
sections
– Median - divides the body
into equal left and right
parts
• Axial (Horizontal or
Transverse) - divides the
body into upper and lower
segments
Sagittal plane Alignment
 Spinal column-a
complex structure
 Vertebrae in the
different regions of
spine position
themselves in a posture
we designate as
LORDOSIS or
KYPHOSIS
Sagittal plane Alignment
• Efficient energy
absorption by spinal
column
• Increases the efficiency
of spinal musculature
• Functions to maintain
head in space
Normal sagittal balance?
• SRS Working Group
Classification Nomenclature:
*Congruent postural alignment of
cervical lordosis, thoracic kyphosis
and lumbar lordosis
*Proportional and produces a
sagittal plumbline passing from the
centre of C7 through the L5-S1 disc
space or within 2 cm of sacral
promontory and through or behind
the hip axis
Patient positioning for standard
lateral radiograph of the spine
• 3-feet long cassette
• Thoracic, lumbar and
sacral levels imaged
• Patient stands with arms
supported in front of
them, the head facing
forward
• X-ray tube is positioned
72” from the patient
Adolescent Idiopathic Scoliosis
• Patient Evaluation
• Natural History
Scoliosis in Children
 Scoliosis is a complex, 3-dimensional deformity:
– coronal
– sagittal
– axial
 Worldwide prevalence of 1%
Scoliosis in Children
Etiologies of Scoliosis
• Moe1 lists over 50 scoliosis etiologies
• Four broad classifications:
– Neuromuscular
– Congenital
– Curves resulting from a specific disorder
– Idiopathic
Patient Evaluation - History
 Growth Profile
– Growth spurt
– Menses
 Symptom Profile
– Cosmesis
– Pain
 Patient Profile
– Medical history
– Family history
Examination
• Alignment
– Scoliosis
– Kyphosis
•
•
•
•
•
Range of Motion
Gait
Palpation
Joints
Neurological examination
Patient Evaluation - Neuromuscular
Neuromuscular Curves
• Onset usually during childhood
• High risk of progression, cardiopulmonary
complications
• Diminished life expectancy
• Neuropathic
– Affects CNS
– Cerebral palsy, poliomyelitis, etc.
• Myopathic
– Affects muscle tissue
– Duchenne’s muscular dystrophy
Myopathic
scoliosis
Neuropathi
c scoliosis
Neuromuscular
•
•
•
•
•
•
Symptoms
Family History
Gait
Gower’s
Neurological exam
Superficial Abdominal Reflexes
Neuromuscular – MRI?
•
•
•
•
Syrinx
ACM
Tether
Split Cord
•
•
•
•
•
Atypical curve
Kyphotic
Neurological dysfunction
Preoperative
Funky
Patient Evaluation - Congenital
Congenital Curves
• Malformation of vertebral segments
during embryonic development
• Not genetic; insult to embryo
• Present at birth
• 3 basic types
– Failure of formation
– Failure of segmentation
– Combined defects
Congenital Spinal Anomalies

1.
2.

2 basic groups
Defects of formation e.g. hemivertebra
Defects of
segmentation unilateral unsegmented
bar
Often both present
Segmentation disorders
•
1.
2.
3.
Location in order of
frequency:
Cervical spine: C2-3, C5-6
Lumbar spine: L4-5
Thoracic spine: any
section
Associated Anomalies
•
•
•
•
Spinal cord anomalies - 15%
G.U.T anomalies - 33%
C.H.D - 10%
Miscellaneous
CONGENITAL vs IDIOPATHIC
• RAPID PROGRESS
• NEUROLOGICAL DEFICITS
• PULMONARY COMPROMISE
Patient Evaluation - Syndromal
Curves from a Specific
Disorder
•
•
•
•
•
Syndromal - Marfan’s, neurofibromatosis
Tumour - osteoid osteoma
Infection - TB
Trauma
Iatrogenic
Marfan’s Neurofibro
syndrome -matosis
Examination
• Syndromal abnormalities
– Café-au-lait, hairy naevus
– Ligamentous laxity
– Eye, palate, heart
Neurofibro
-matosis
J.G.
• 8+8 F
• NF-1
• Chiari 1 + cervical syrinx – decompressed
June 08
• No neurology
• Dural ectasia but no neurofibromata on
MRI
• T10-L3 52°now (30° in April 08)
Deformity (Neurofibromatosis)
Pain
• Not typical in scoliosis
• ?Disc pathology
• ?Osteoid osteoma
• ?Infection
Osteoid Osteoma
J.C. F7 Hurler’s Syndrome TL
Kyphosis
J.C. F7 Hurler’s
Age 4
Age 7
Aetiology
Idiopathic Scoliosis
• Unknown cause
• 85% of all scoliosis cases
• 3 types
– Infantile (birth - 3 years)
– Juvenile (3 - 10 years)
– Adolescent (10 - 17 years)
Idiopathic Scoliosis
• Adolescent
– Over 80% of surgical cases
– Many have onset during juvenile period
– Frequency of females to males requiring surgical treatment is
approximately 9:1
– High degree of variability in curve progression
Classification of Curves
•
Curve pattern: describes the anatomic location and the
direction and number of curves
– Location - Upper thoracic, mid-thoracic, TL, mid-lumbar
– Direction - Right curve = concavity on patient’s left
– Number - 1, 2, or 3 curves
Classification of Curves
•
Curve magnitude
– Measured in degrees of curvature
– Major curve
• Larger structural curve
• Does not bend out on x-rays
– Minor curve
• Non structural
• Also called secondary or compensatory curve
• Bends out on x-rays
Cobb Angle Measurement
• Curve magnitude measured in
degrees of curvature
• Cobb angle method most
common
• Standard full-length AP
needed
Axial Rotation
• Curve magnitude also measured by axial plane rotation of
vertebrae
• Generally, the more rotation, the more severe the curve
• Nash-Moe Pedicle Shadow Technique most common
Classification of Curves
•
King Classification
– Describes thoracic curves
– Does not consider sagittal plane deformity
King Type I
King Type II
King Type III
King Type
IV
King Type V
Classification of Curves
•
Lenke Classification
– New treatment-based
system
– Considers sagittal
plane, thoracic and
lumbar curves
Risk of Curve Progression
• Key question for surgeons: “Will curve progress?”
• 5 main indicators:
–
–
–
–
–
Gender of the patient
Magnitude of the curve
Curve pattern
Age at onset of the curve
Skeletal maturity of the patient
Curve Progression
Risser 0-2 immature
Risser 3-5 mature
Natural History of Idiopathic
Scoliosis – Immature (Risser 0-1)
• Lonstein & Carlson
– 20-29 degrees
– >30 degrees
68%
60-90%
Natural History Untreated AIS
 Weinstein SL JAMA 2003
– 50 yr study 117 untreated patients 1938 – 1942
– Age & gender matched controls
–
–
–
–
–
–
Mortality
LBP
Pulmonary Symptoms
General function
Depression
Body image
 61% LBP vs. 35% in controls
 SOB Cobb>80 degrees
 Cosmesis and LBP main complaint
F78 Scoliosis, Stenosis, Neurogenic
claudication
Quality of Life Untreated AIS
• 226 females
• SF36
•
•
•
•
Low self esteem
Depression
Psychological complaints
Physical impairment
• Friedel K et al Spine 2002
Adolescent Idiopathic Scoliosis
• Largely cosmetic
• Not typically painful
• Cardio-respiratory compromise
– Curves > 80 degrees
Scoliosis Treatment
Treatment of AIS
• Options
– Observation
10 – 25 deg.
– Bracing
25 - 45 deg.
– Surgical intervention
>45 deg.
• Factors
–
–
–
–
Age of patient and growth potential remaining
Curve pattern and magnitude
Curve progression rate (5-10 degrees in 6 months or less)
Cosmetic appearance
Observation
• Frequent observation
• Case example
– Treatment by observation
– Increased 7 degrees in 5 years without
treatment
– Classified as a non-progressive curve
Nonoperative Treatment
• Casting
– Not as common today
– Requires traction
– “Plaster jacket” frequently used in
treating infantile scoliosis
• Orthotics
– Primary nonoperative treatment used
today, also called bracing
– Two essential functions
• Improve the deformity initially
• Prevent curve progression
– Must be worn 16-18 hours a day to be
effective
Milwaukee Brace
Boston Brace
Non-operative treatment
• Bracing
– Curves 20 – 40 degrees
– Progression 18-50%
– Self – image
– Compliance
Weinstein JBJS 1983
Peterson SRS Brace Study JBJS 1995
Rowe Meta-Analysis JBJS 1997
Instrumentation and fusion
• Indications
• > 45 degrees
• progressive curve
despite non-operative
treatment
Operative Treatment
• Primary objective in AIS is to achieve a solid arthrodesis
(fusion)
• Infantile and juvenile scoliosis may be treated with
instrumentation without fusion using a growth rod
• Instrumentation implies internal fixation of the spine
– Posterior
– Anterior
– Anterior-posterior procedure
• Internal fixation devices have two main functions
– Help correct the deformity within safe parameters
– Maintain correction until the arthrodesis is solid
History of Scoliosis Correction
Luque Sublaminar wires
–
Harrington Instrumentation
– Rod anchored at ends by hooks
– Distraction
– Post op cast needed
– Flat Back Syndrome
(no concern for sagittal
alignment)
Pedicle hooks
Rod rotation
–
3-dimensional correction
–
Sagittal plane
–
Derotation of vertebra
–
Multiple fixation points
–
Rod bending critical
–
Compression/ distraction
–
CD - Cotrel & Dubousset
Posterior instrumentation example
Translation
–
Laminar claws
–
Sub laminar wiring
–
Reduction devices
using hooks
–
–
Pull spine to rod
Large rod diameter
Anterior correction
–
Advantages
– Discectomy improves
flexibility of curve &
correctability
– Fewer levels fused
– Arthroscopic
applications
–
Disadvantages
– Great vessels,
sympathetic chain,
diaphragm
– Postoperative
morbidity
Implant Developments
– Polyaxial
– Lower profile implants
– Dual-Core screws
Case Study: Right Thoracic AIS treated with
anterior spinal fusion
Preo
Posto
Thoracic Pedicle Anatomy
• Cinotti Spine 1999
– Pedicle axis intersects
superior facet
• middle
• lat 1/3 62%
• lat border
15%
23%
• Narrow at T4-6
– 68% <5mm at T4
Implants
• Key implants
– Screws
– Hooks
– Rods
– Sleeves
– Nut
System description
Titanium Alloy (TAN) and Stainless Steel
(SST)
Case Study: thoracic scoliosis; posterior
spinal fusion T4-L2
Preo
Posto
Thorascopic Scoliosis
• Image guided or
fluoroscopic guided
endoscopic implantation of
fixation system
Thoracic Endoscopy
Thoracic Endoscopy
Thoracic Endoscopy
Thoracic Endoscopy - Instruments
FUSIONLESS DEFORMITY CONCEPT
Shape Memory Alloy (SMA) Staples
FUSIONLESS DEFORMITY CONCEPT
Shape Memory Alloy (SMA) Staples
Juvenile/Adolescent Idiopathic
Scoliosis - Staples
• Immature patients
• 20-40 degree curves
• Betz Spine 2003
A Fusionless Deformity Concept
Braces
54°
54°
9 yrs premenarchal, open triradiates, normal MRI,
rapid progression 40°->54°, despite bracing
Case Study – F8, Premenarchal,
Risser 0, Open Triradiates
? Brace
39°
?? Apical Fusion
?? Growing rods
?? Ant/Post Fusion
??? Staples
Convex Vertebral Body Stapling
Hypothesis:“Staples hold convex side of
curve as the child grows,
stabilizing the curve and
potentially even correcting
it”.
F 13 R Thoracic curve
improved from 35° to 27° at
1yr f/u
Surgical technique
Generally, 3 - 4 portals in the posterolateral line are used with the
thoracoscope being inserted in the anterior axillary line at the apex of
the curve
Surgical technique
The staple trial is centered over the intervening disc space for staple
sizing
Surgical technique
Final seating is completed using the tamp
Surgical technique
If a staple is not in the desired location, the staple can be removed and
repositioned
OPERATIVE SETUP
SPINAL CORD MONITORING
Who to Refer?
• 20 degree curve in skeletally immature
individual
• Syndromal?
• Neuromuscular
• Funky
• Concern – parents, GP
What Investigations?
• Erect XR TL Spine AP/Lat
• If painful
– WCC, CRP, ESR, ANA, HLAB27, RhF
– Bone Scan
Kyphosis & Lordosis
• Spondylolisthesis & Lordosis
Dysplastic angle
Spondylolysis/ Spondylolisthesis
•
•
•
•
•
•
Incidence 6%
Adolescents
Stress remodelling reaction -> slip
Usually “isthmic”
Boys > girls 2:1
Progression worse in girls
Preoperative Evaluation - Radiological
• Slip
• Slip angle
• Disc height
Spondylolysis
L5 pars #
Low back pain
Teenage growth
spurt
Spondylolysis
• Activity modification
• 6 weeks bracing
• Lysis injections
Bone Scan
Surgery
- Intractable back
pain
- High level athletes
Direct pars repair
Spondylolisthesis
• Slip of one vertebra in
relation to an adjacent
vertebra
• Slipped vertebra carries
entire load of vertebral
column above
• Spondylolisthesis is a
forward slip Retrolisthesis
is a backward slip
Lateral listhesis is a
sideways slip
• Most often at L4-5, L5-S1
Preoperative Evaluation - Radiological
• Slip
• Slip angle
• Disc height
Isthmic Spondylolisthesis – Meyerding
Grading
Spondylolisthesis
Anatomy
• Usually result of defect in pars interarticularis
• Micro fractures in pars from repeated, excessive
loads (fast bowlers, gymnasts have high
incidence)
• Disc degeneration associated with most forms of
spondylolisthesis
Spondylolisthesis – Clinical
Features
•
•
•
•
•
•
Pain – low back, groin, buttocks
Tight Hamstrings
Decreased flexion, pain on extension
Short waistline
Flat buttocks
Palpable step-off
L5/S1 Spondylolisthesis
• Usually grade 1
• Requires XR check 6 monthly through
growth
• Most LBP will settle with conservative
measures
• Nonunion pars # is typical
Spondylolisthesis
• Surgery
– Progressive slip
– Neurological
involvement
– Intractable pain
– Surgical indications
and techniques a
widely debated subject
Preoperative Evaluation - Radiological
• Neural compression
Preoperative Evaluation - Clinical
• Low back pain
• Abnormal gait –tight
hamstrings
• Deformity
• Claudicant pain
• L5 radiculopathy
• Cauda equina ?preoperative
urodynamics
Preoperative Evaluation - Radiological
• Neural
compression
Pain Generators
Case 1 Preoperative Evaluation - Clinical
• Low back pain
• Abnormal gait –tight
hamstrings
• Deformity
• Claudicant pain
• L5 radiculopathy
• Cauda equina ?preoperative
urodynamics
Preoperative Evaluation - Radiological
• Disc height
Lumbosacral
angle
L5 Trapezoidal
L4 Incidence
angle
Postop
Role of
Decompression
• Allows neural
decompression
• May be unnecessary
– Radiculopathy, hamstring
tightness resolves with
fusion alone
• Less bone surface for graft
• More prone to slip
progression if not
instrumented
Translational Pedicle Screws
• M15
• Unremitting LBP,
Bilateral L5 radicular
pain
• Time off school
• No relief from
analgesics
Preoperative
12 months postoperative
F8 Grade3/4 slip, neuro intact
- posterior decompression, pedicle
screws, posterolateral fusion,
F8 Grade3/4 slip, neuro intact
- posterior decompression, pedicle
screws, posterolateral fusion, solid
at 8 years, asymptomatic
L5/S1 ISTHMIC SPONDYLOLISTHESIS
Case – Isthmic Spondylolisthesis
• M15
• Unremitting LBP,
Bilateral L5 radicular
pain
• Time off school
• No relief from
analgesics
• Temporary relief from
lysis injection only
Preoperative
12 months postoperative
Scheuermann’s
•
•
•
•
•
Structural
>45 degrees in thoracic region
Vertebral wedging
May affect lumbar region as well
Common cause of pain
Postural kyphosis
Structural
kyphosis
Thoracic kyphosis
 20 to 50 degrees
- Bernhardt and Bridwell [Spine 1989;14] ;
- Boseker et al [J Ped Orthop 2000;20] ;
- Takemitsu Y et al[J Japanese Orthop
Assn[1977;51])
Radius of Curvature
• The measure of how
smooth or angular a
deformity is
• The greater the
radius, the smoother
the curve
• Curves that are more
angular have a greater
risk of progression
• 1921 Holger
Scheuermann
• Vertebral wedging
caused by growth
disturbance of
endplates
• 0.5 to 8% of healthy
subjects; M=F
Etiology – UNKNOWN
• Scheuermann – Aseptic
necrosis of ring apophyses
• Weak cartilagenous
endplates with associated
Schmorl nodules
• Ascani et al – Growth
Hormone hypersecretion
• Bradford et al – Juvenile
Osteoporosis
• Genetics – AD?
FINAL COMMON PATHWAY
- DIFFERENTIAL GROWTH
Types
a) Thoracic (apex T7-T9)
b) Thoracolumbar (apex T10- T12)
c) Lumbar form
• Pre-pubertal phase, about 10 years
• Differential Diagnosisa) Postural kyphosis
- Forward bending test & correctability with posture
b) Congenital kyphosis - angular gibbus
c) Spinal infections – angular gibbus
d) Skeletal dysplasia – generalised
Natural History
• Benign
• Back pain
• Curves<600 at skeletal maturity do well
(Lowe)
• Significant morphological evolution but no
clinical/ functional problems (Travalgini et al)
• Significant pain & tenderness compared to
controls (Murray et al)
Investigations
•
a)
b)
c)
Xrays
Standing lateral x-ray of entire spine
Standing AP x-ray of entire spine
Passive hyperextension test
•
MRI
Treatment
•
•
•
•
•
Observation
Physical therapy
Bracing
Casts
Surgery
Physical therapy
- Strengthening of extensor muscles
- Aerobics to maintain flexibility
Bracing
• Exercises
– symptom relief
– Do not alter progression
• Milwaukee hyperextension
brace
Indications for Surgery
•
•
•
•
Rapidly progressive kyphosis
Pain refractory to non-surgical means
Compromised pulmonary function
Spinal cord compression
Surgery
• Aims: a) To prevent progression of deformity
b) To correct the existing deformity
• Approaches
- Posterior
-A+P
- Anterior
• Principle
- Posterior  Cantilever + Compression
- Anterior + Posterior  Ant release +posterior fusion
- Anterior only  Ant release + instrumented inter-body fusion
Passive Hyperextension Test
Curve < 50 deg
Posterior procedure
Curve > 50 deg
Anterior + Posterior
procedure
Anterior release + Post fusion
• Thoracotomy
• Release of ALL
• Multilevel apical
discectomies
• Interbody fusion with
morsellised bone-graft
Surgery – Fusion levels
Posterior Surgery
• Apical osteotomies
• Anchors – claw constructs/
screws
• Rod contouring
• Seating of rods superiorly
• Correction by Cantilever
mechanism +
Compression
Case Illustration
•14 years old
•Back Fatigue
•Chest deformity – Pectus
Carinatum
•Thoracic Kyphosis= 80 deg
Surgical Treatment
• Operative
– Indications
• Significant cosmetic deformity
• Patients who are poor candidates for conservative
therapy
– Instrumentation with fusion is surgical
treatment of choice
• Posterior, anterior, or combined approach