Paediatric Idiopathic Scoliosis Flashcards Preview

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Flashcards in Paediatric Idiopathic Scoliosis Deck (28):
1

Define adolesent idiopathic scoliosis?

  • scoliosis in children >10 years old
  • most common type of scoliosis

2

What is the epidemiology of adolscent idopathic scoliosis?

  • Incidence of 3% for curves 10-20o
  • Incidence of 0.3% for curves >30%
  • 10:1 Female vs male for curves >30o
    • 1:1 M:F for small curves
    • right thoracic curves most common 
    • left curves rare- need MRI to rule out cyst/syrinx

3

Describe the pathophysiology of adolescent idopathic scoliosis?

  • Unknown
  • potential causes
    • Multifactorial
    • hormonal- melatonin
    • Brain stem
    • proprioception disorder
    • platelet
    • calmodulin
  • most have positive FHX

4

What is the prognosis of adolscent idopathic scoliosis?

  • Natural hx
    • increased incidence of acute and chronic pain in adults if left untreated
    • Curves >90o assoc with cardiopulmonary dysfunction, early death, pain and decreased self image

5

What are the risk factors for curve progression?

  • Curve Magnitude
    • before skeletal maturity
      • >250 will continue to progress
    • after skeletal maturity
      • >50o thoracic will progress 1-2o pa
      • >40o lumbar will porgress 1-2o pa
  • Curve Type
    • Thoracic more likely to progress than lumbar
    • double curves more likely to progress than single curves
  • Remaining skeletal growth
    • Younger age <12yrs
    • Tanner stage <3 females
    • Risser stage <3 females
    • open triradiate cartilage
  • peak growth velocity
    • best predictor of curve progression
    • in females just before menarche & before Reisser 1 ( girls reach Sk maturity 1.5yrs post menarchy)
    • if curve is 30o B4 peak growth velocity strong likelihood of surgery

 

6

What is Risser Stage used for and can you describe it?

  • Used to identify Maturity of skeleton
  • V is fused
  • 1 is apophysis at anterior edge

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7

How is adolscent idopathic scoliosis identifed?

  • School screening on adams forward bending test
  • 7o abnormal = 20o coronal plane curve
  • axial plane deformity indicates stuctural curve- see pic
  • forward bending sitting test can eliminiate leg length inequality as cause of scoliosis

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8

What other important signs are seen on examination in a pt with adolscent idopathic scoliosis?

  • Leg length inequality
  • midline skin defects- hairy patches, dimles, nevi
    • signs of spinal dysraphism
  • shoulder height difference
  • truncal shift
  • rib rotational deformity- rib prominence
  • waist asymmetry and pelvic tilt
  • cafe-au-lait spots
  • foot deformities
    • cavovarus-? neural axis deformity =MRI
  • Asymmetric abdominal reflexes
    • preform MRI

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9

What is seen on xrays with a pt of adolscent idopathic scoliosis?

  • Standing PA and lateral
    • Cobb angle 
      • >100 = scoliosis
    • Spinal Balance
      • plump line C7-post -superior corner S1

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10

When are MRI indicated in adolscent idopathic scoliosis?

  • left sided curves
  • rapid progression
  • excessive kyphosis
  • neurological symptoms
  • assymetrical abdominal reflexes
  • foot deformities

idea to rule out intraspinal anomalies

11

What is the tx of adolscent idopathic scoliosis?

Non operative

  • Obervation alone
    • if cobb angle <25o
    • serial xrays review progression
  • Bracing
    • Cobb angle 25-45o
    • in immature Pt Reisser 0-2
    • goal to stop progression not correct deformity
      • poor prognosis
      • male, obesity, hypokyphosis, noncompliant

Surgery

  • Posterior spinal fusion
    • Cobb >45o
    • gold standard for thoracic/ double curves
  • Anterior spinal fusion
    • best for thoracolumbar/ lumbar cases with normal sagittal profile
  • Anterior/Posterior spinal fusion
    • large curve >75o & stiff
    • young age risser 0
    • prevent crankshaft phenomenon

12

Describe the technique of bracing in adolscent idopathic scoliosis?

  • recommended for 16-23 hours a day until skeletal mature or surgical innervention necessary
  • Brace types
    • Curves above T7
      • milwaukee brace- Cervicothoracolumbosacral orthosis-CTLSO
    • Apex at T7 or below
      • Thoracolumbosacral orthosis TLSO
      • boston brace

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13

What is the techique of surgery

  • Posterior spinal fusion
    • aims
      • to include enough levels to maintain sagittal and coronal balance whilst being minimal as safely possible
      • typical fusion prox end of vertebra to one/two levels cephalad to stable vertebra
    • Harrington technique
      • 1 level above to 2 levels below the end vertebra
    • L5 level- cochran found increaed incidence of low back pain with fusion to L5, and lesser extent L4
      • try to avoid fusion L4/5
      • pelvis almost never fused in idiopathic scoliosis

14

What is monitored in adolescent idiopathic scoliosis surgery?

  • Somatosensory -evoked potentials SSEPs
    • allow identication of injuries from positioninf
    • most common reversible intraop neurological injury
  • Motor-evoked potential - MEPs
    • provide intraop warning of impeding spinal cord dysfunction

15

What happens if neurological injury occurs in theatre whilst monitoring SSEPs/ MEPs?

  • Lessen reverse correction
  • check HB and transfuse
  • elevate BP
  • administer Stagnaras wake up test
    •  waking the patient during the surgery and asking them to move their feet.
  • remove instrumentation if spine stable

16

Complications of spinal surgery on  adolescent idiopathic scoliosis?

  • Neurological injury
    • 1:1000
  • Pseudoarthrosis
  • Infection 1%
    • late pain
    • incision often looks clean
    • Propionibacterium acnes - most common organism for delayed infection
  • Flat back syndrome
    • early fatigability & pain due to loss of lumbar lordosis
  • Crankshaft phenomenon
    • rotational deformity of spine ctreated by continued anterior spinal growth in setting of post fusion
    • avoid by preforming anterior discectomy + fusion with post fusion in young pt
  • SMA syndrome- superior mesenteric artery syndrome
    • pc bowel obstruction
    • tx with NG tube and iv fluids
  • Hardware failure
    • late rod breakage

17

What is juvenile idiopathic scoliosis?

  • scoliosis in children <10 years

18

What is the epidemiology of  juvenile idiopathic scoliosis?

  • Greater in females than males
  • mainly appear right sided thoracic curves

19

What are the associated conditions of juvenile idiopathic scoliosis?

  • high incidence of neural axis abnormalities = 18-25%
    • Syringomyelia
      • cyst/tubular cavity within spinal cord
    • Arnold-Chiari syndrome
      • cerebellar tonsil are elongated. Protrude thru thr opening of base of the skull and blocking CSF flow
    • Tethered cord
    • Dysraphism
    • spinal cord tumours

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20

How do they present with  juvenile idiopathic scoliosis?

  • School screening
  • ADAMS forward bending test
    • abnormal 7o= 20o coronal plane curve
  • cafe au lait spots
  • leg length discrepancy
  • shoulder height difference
  • truncal shift
  • rib rotational 
  • waist asymmetry
  • foot deformity- cavovarus
  • asymmetrical abdo reflexes

 

21

What is seen on imaging of juvenile idiopathic scoliosis?

  • Xrays PA &  lateral upright 
  • Cobb angle >100
  • MRI those who <10 years with curve >20o

22

What is the tx of  juvenile idiopathic scoliosis?

Non operative

  • Observational
    • curves <20o
    • freq radiographs- see curve progression
  • Bracing
    • curves 20-50o
    • prevent curve progression, no correct deformity
    • CI thoracic hypokyphosis
    • 16-23 hrs until skeletal mature

Surgery

  • Non fusion proceedure- growing rods
    • Curves >50o in small children- alot growth left
    • allow continued spinal growth
    • Definitive PSF +ASF when child grown
  • Anterior/posterior fusion
    • Curves >50o in younger pts
    • to prevent crankshaft phenomenon
  • Posterior Spinal fusion
    • curve >50o in older pt skeletal mature
    • gold standard doublecurves/ thoracic curves
  • Anterior spinal fusion
    • curve >50 degrees with thoracolumbar/thoracic cases w normal sagittal profile

23

Define  infantile idiopathic scoliosis?

  • Scoilosis that presents prior to age 3

24

What is the epidemiology of infantile idiopathic scoliosis?

  • 4% of idiopathic scoliosis cases
  • more common in MALES
  • autosomal dominance w variable penetrance
  • location
    • usually LEFT THORACIC
  • ​Risk factors
    • most resolve spontaneously
    • apical vertebra rib overlap places curve at high risk of progression

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25

What is infantile idiopathic scoliosis associated with ?

  • Plagiocephaly- skull flattening
  • Congenital defects
  • Neural axis abnormalities
    • 22% pt with curves >20o
    • 80% of these will need neurosurgery
  • Cardiopulmonary involvement
    • pulmonary function affected curves >60o
    • Symptomatic when curve >90o

26

What do you look for on exam of a pt with infantile idiopathic scoliosis?

  • Skin
    • cafe- au- lait- NF1/2
    • patches of hair, dimpling, naevi- spinal dysraphism
  • Cranial 
    • plagiocephaly
  • Motor
    • milestones
    • lower extremity - cavovarus
    • abdo reflexes- syrinx

27

What investigations are useful in infantile idiopathic scoliosis?

  • Cobb angle
  • evaluate phase of rib position- medial rib position w repsepct to apical vertebra
    • phase 1
      • no rib overlap
    • Phase 2
      • rib overlap with apical vertebra
      • high risk of curve progression
    • Rib Vertebrae angle difference - RVAD/Mehta angle 
    • >20 linked to high rate of pregression
    • <20 assoc with sponataneous recovery

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28

What is the tx of infantile idiopathic scoliosis?

Non operative

  • Observe alone
    • Cobb angle <30o
    • RVAD <20o ( rib vertebrae angle difference)
    • 90% resolve spontaneously
  • Serial Mehta casting (derotatonal )or thoracolumbosacral orthosis TLSO
    • Cobb angle 25-30
    • Phase 2 rib vertebra relationship

​​Operative

  • Growing rod construct ( dual rod or VEPTR)
  • cobb angle >50-60 degrees
    • allow growth of spine up to 5cm
    • anchors proximal and distally
    • serial lengthening

 

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