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Pathology > Spinal Deformities II > Flashcards

Spinal Deformities II Flashcards

1.Define and recognize common chest deformities. 2.Describe the different types of kyphotic posture. 3.Describe common characteristics of scoliosis. 4.Describe the four common scoliotic curves. 5.Describe the difference between structural and functional scoliosis. 6.Describe clinical methods (physical exam and radiographic) used for assessment of scoliosis. 7.Describe common treatment strategies for scoliosis.

1
Q

Chest Deformities

A
  1. 1 in 600 persons have abnormal overgrowth of the lower costal cartilages between the ribs and sternum
  2. Types of Deformities
    - Pectus excavatum
    - Pectus Carinatum
    - Barrel Chest
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2
Q 
Pectus Excatavum (90%)
picture
A
  1. Funnel Chest
    -excavate= to hollow out
  2. •Most common congenital chest wall deformity
    –1:300  1:1000 births
    –M:F = 3:1, caucasian
    –Problematic for females
    –Most are sporadic
    –35% familial occurrence
    –Marfan’s syndrome association
    3.Sternum posterior
    –A/P of thorax decreased
    4.Ribs anterior to sternum
    –Overgrowth of 4-5 ribs
    –Heart pushed left
    5.Treatment
    –Shoulder girdle strengthening
    •Pectoralis muscles
    •Posterior scapular muscles
    •Surgery if severe
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3
Q

PA chest xrays

A

PA chest x-rays of 16 yo male demonstrate leftward shift of the mediastinum and blurring of the right heart border. Lateral view confirms marked pectus excavatum deformity.

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4
Q

Pectus Carinatum (5-7%)

A 
1.“Pigeon Breast”
•carina  ridge-like
2. Sternum protrudes anterior and inferior
3. Caucasian males 4:1
4. Impairment
–Mobility restriction
–CP function?
•Decreased air intake
•Ineffective coughing
•Mitral valve prolapse
–Marfan’s syndrome
5. Treatment
–Pectoralis mm. exercises
–Mobility exercises to increase rib cage mobility
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5
Q

Pecus Carinatum Pictures

A

sternum sticks out and down to the front

limit excursion of chest wall

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6
Q

Marfan’s Syndrome

picture

A 
•Inherited connective tissue disorder
–Autosomal dominant  1:3,00010,000
–Panethnic with no sex predilection
–3/4 have affected parent
–Single gene codes glycoprotein “fibrillin”  substrate needed for microfibril formation and elastin in aorta
•Mitral valve prolapse (97%)
•Aortic root dilatation/aortic dissection
–Untreated  death 30-40 yo
–Tall in stature
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7
Q

Marfans Syndrome and Michael Phelps

A
  1. Wing span greater than height
  2. Pectus carinatum
  3. Joint hyperflexibility
  4. Long narrow face
  5. Small jaw
  6. Overcrowding of teeth
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8
Q

Barrel Chest

picture

A
  1. Sternum/rib cage protrudes anterior and superior
    - -Increased A/P thorax diameter
  2. Seen in patient with COPD and emphysema
    - -Rib cage frozen, “unit movement”
  3. Rib mobility
    - -Rib mobility exercises
    - -Trunk flexibility exercises
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9
Q

Chest Deformities

A
  1. While in the vast majority of cases, importantly pectus deformities cause NO significant physical or medical problems
    –Usually displaces heart into left chest
    –Limits full lung expansion
    –Unattractive appearance->psychological disturbances
    +Self-esteem issues
    +Body-image issues
  2. Children occasionally experience
    a. decrease in exercise stamina and endurance
    b. Pain or discomfort in lower chest (muscle positioning)
    c. Deformity becomes more severe during adolescent growth
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10
Q

Decisions for Surgery

A
  1. Chest radiograph
    - for recommending surgery
  2. CT scan and pulmonary function test expensive and do not influence decision for surgery
  3. 96% have very good to excellent results with surgery
  4. Operation easiest and recovery faster in preadolescent children
    - -Intails surgical steel bar placement under sternum
  5. Post- Surgery
    - -Medical alert bracelet recommended
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11
Q

Kyphosis

A

Kyphos=hump

A posterior deviation of the spine in the saggital (front to back) plane beyond normal limits (between 20-40 degrees)

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12
Q

Types of Kyphotic Posture

A

Postural kyphosis
Scheuermann’s kyphosis
Congenital Kyphosis

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13
Q

Postural Kyphosis

A
  1. Not a pathological condition; diagnosed by lack of structural abnormalities of the vertebral bodies
  2. Most Common type
    esepcially in girls
    poor adolescent posture; rounded, slouched shoulders
  3. Treatment
    -early (pre-teens)->agressive Postural exercises
    -late (teens)->spinal bracing
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14
Q

Scheuermann’s Kyphosis: 2 types

A
  1. T-spine
    -Hereditart, progressive, non-painful
  2. Dorsolumbar
    –excessive trauma or loading on the immature spine
  3. T-spine: results from empryonic failure of vertebral formation or vertebral segmentation
  4. Progresses if left untreated
    –50-70% is treated by bracing
    –>70-75% or significant pain–requires surgery
    excising abormal discs, fusing vertebrae, placing rods
    –PT treatmetn alone is not usually effectove
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15
Q

Scheuermann’s Kyphosis

A

PICTURE
Normal spine with forward bending…
Gibbus Deformity= pronounced, rigid curve with forward bending

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16
Q

Surgery for Scheuermann’s Kyphosis

A

Rods inserted into the spine

17
Q 
Congenital Kyphosis
(even kyphotic in prone--structural)
A

Genetic anterior defect  causing a posterior deviation
–Anterior wedge-shaped deformity of 3 to 5 Thoracic-vertebrae
–Unlike in postural type, persists when patient is prone
•Treatments
–Early detection  extension exercises, Milwaukee brace
–If near boney maturity bed rest in extension,
body cast, surgical fusion for severe cases
•> 75°and apical vertebra wedged > 15°

18
Q

Congenital Kyphosis: Thoracic/Lumbar Junction

2 congenital Types

A
  1. Failure of Formation (I) deformity

2. Failure of separation (II) deformity

19
Q

Other Types of Kyphotic Posture

A
  • Neuromuscular  CP, MD, Polio
  • Post-traumatic  with serious injury
  • Post-laminectory  treating spinal stenosis
  • Associated with dwarfism
  • Post-menopausal  osteoporosis
20
Q

III. Scoliosis

A
  • Scolios = “crooked, curved”
  • Abnormal lateral spine deviation associated with vertebrae rotation
  • Spinous processes rotate toward curve concavity
  • Vertebral body toward convexity
21
Q

Overview of scoliosis

A
  • Research indicates 90% of idiopathic is genetic
  • Programmed at conception, but expresses itself 10-12 years later
  • Sex-linked trait transmitted by mother
  • Variable expression
  • Some Proposed Causes:
  • Minor dysfunction of brainstem development
  • Lesion in posterior columns of spinal cord
  • Balancing mechanisms of inner ear
22
Q

Scoliosis Name by

A

Area of spine that the curve is in. and the side which the apex of the curve is on. Picture –named by convexity!!
Screen Forward Bend–pretty specific

23
Q

Scoliosis: Overview

A 
•1 in 10 children affected, with 1 in 4 (25%) of those requiring treatment
•Right thoracic curvature and left lumbar curvature most common
•Age of onset
–Infantile (0-3 yrs)
•Rare in US
–Juvenile (3-10 yrs)
•Right thoracic, rapidly progressive
–Adolescent (After 10 yrs)
•Females (12 yrs); male (14 yrs)
•Females 10:1 males
24
Q

Common Characteristics of scoliosis

A

•Asymmetrical shoulders or pelvis
–Often detected with school screening exams or routine doctor visits
•Designated RIGHT or LEFT convexity
•Usually have primary curvature with compensatory curve to balance the body

25
Q

Common Characteristics of scoliosis

A

A•Compensated vs. Uncompensated
1–Compensated
•Spine curvatures balanced with head centered over pelvis
2-Uncompensated
•Head not balanced over pelvis
B•Gibbus rib hump
–Rotational deformity on the convex side apparent in Adam’s forward bend test

26
Q

most common rib hump?

A

Right Rib Hump because most common scoliosis is Right Scoliosis

27
Q

Structural vs. Functional

A
  1. Functional (Non-structural)
    –No boney deformity, curve flexible and symmetrical, corrects on convex side bending)
    –Ex. Pain  spasm or inflammation, poor posture, leg length discrepancy
    –May become structural is untreated
    2•Structural
    –Boney deformity, rigid (fixed) asymmetrical curve, does not correct with side bending to convex side; vertebral body deformity
    –Possible causes= idiopathic, neuromuscular, metabolic, congenital, post-traumatic
28
Q

Etiology Scoliosis

A

•Idiopathic
–Unknown cause (probably genetic)
•80% of all cases
•Osteopathic (congenital)
–Due to spinal disease or bony abnormality
•Myopathic
–Due to trunk muscle weakness, i.e., muscular dystrophy
•Neurologic
–Due to neurologic disorders, i.e., cerebral palsy

29
Q

Pathogenesis of Scoliosis

A

•Understood better if you know underlying cause
•Earliest changes associated with soft tissues (shortened muscles, ligaments, etc.) on concave side of curve
•With progression, bone deforms due to asymmetrical compression applied to the epiphyseal ossification center of developing vertebral bodies
•Compression forces greatest on the vertebrae in apex of the concavity
–Apical vertebrae become most deformed

30
Q

Four Common Types by curvature

A

Thoracic Curve
Thoracolumbar Curve
Lumbar Curve
Double Major Curve

31
Q

Four Common Types by Curve

A 
Thoracic Curve
–Most common if idiopathic
–Cosmetically deforming
–Rapidly progressive
–T4-6  T11-L1 (scapular deviation)
–90% on right side
•Thoracolumbar Curve
–Fairly common if idiopathic
–80% on right side
–T4-6  L2-4
–Less cosmetically deforming
32
Q

Four Common Types by Curve

A 
•Lumbar Curve
–Common, but less visible on physical exam
–70% on left side
–T11-12  L5
–Pelvic obliquity
•Slanted and inclined
•Double Major Curve
–2 equal curves
•R thoracic and L lumbar
–Less cosmetic evidence
33
Q

MEASUREMENTS for Scoliosis

A 
Cobb method (left) measures from upper and lower end vertebrae of curve Sciolometer method (below) measures degree of rotation at curve apex
0=no rotation of pedicle
\+1=pedicle toward midline
\+2=pedicle 2/3 to midline
\+3=pedicle in midline
\+4=pedicle beyond midline
34
Q

Cobb vs. Sciolometer

A

Cobb is better Frontal Plane

Sciolometer is better for Transverse Plane (not used as much)

35
Q

Scoliosis Clinical Manifestations

A

•Mild ( 60 degrees)
–Pulmonary insufficiency & reduced lung capacity
–Back pain with degenerative spinal arthritis, disk disease, vertebral subluxation
–Sciatica
•Diagnosis by clinical exam
–Radiographs  Cobb method measures curve angles
–Scoliometer measures trunk rotation angles
–Bone scan rules out neoplasm, infections, compression fractures
–MRI differentiates cord lesions, disk herniation

36
Q

Risk Factors for Curve Progression

A 
•Female : male :: 10:1
•Thoracic or double major curves
•Curves > 20 degrees
•Skeletal immaturity
–Younger age
–Pre-menstrual females
37
Q

Treatment – Prevention is Key!

A

•Early detection critical to prevent surgical intervention
–Overall goals: prevent severe and progressive deformities
•Management options determined by:
1.Degree of curve
2.Patient age
3.Skeletal maturity and remaining growth
4.Individual preferences

38
Q

Treatment

A

•Conservative (< 25°)
–Observation with Exercises
–E-stim
–Monitor every 4-6 months
•Moderate (between 25-45°)
–Spinal bracing orthoses
•Ex. Boston, Milwaukee, Charleston braces
–Passive restraint to maintain curves within 5 degrees of initial application
•85-88% successful
–Curves with apex from T8-L2 respond best to bracing
•Apex at T6 or above has poorest results
•Severe (> 45-50° or with pain!)
–Fusion with rods at L3-4 or above
•Luque or Harrington rods (posterior fusion)
•Dwyer procedure (anterior fusion)

39
Q

Two Treatment options for scoliosis

A

Bracing and Harrington Rods

Pathology (5 decks)

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