Treatment of spinal deformities Řepko, M., Krbec, M., Chaloupka, R., Ryba, L., Rouchal, M., Motyčka, J. Orthopaedic department Masaryk University Brno University Hospital Brno Ortopedická klinika FN Brno-Bohunice The most common spinal deformities kyphosis SCOLIOSIS Scoliosis is three-dimensional deformity in frontal plane - scoliosis in sagittal plane - hypo, hyperkyphosis in transversal plane - rotation, torsion Scoliosis: 3-D deformity Torsion Elementary primary evaluation anamnesis clinical examination X-ray evaluation treatmen Anamnesis familiar anamnesis complex health status development - sitting, standing, J capture and present treatme ni Clinical evaluation trunk compensation - plumb line shoulder height waist asymmetry pelvic balance curve flexibility in bending position prominence in bending forward others - laxicity, sexual development, skin pigmentation, lenght of lower extremities Measurement of trunk decompensation Measurement of shoul der asymmetry Measurement of paravertebral gibbus Measurement of paravertebral gibbus Sagittal balance 2-2,5 cm tečna 2,5 - 3 cm Shoulder height Gibbus Asymmetry of waist Trunk decompensatio Neurofibromatosis „cafe au lait" Radiological evaluation PA and lateral X-rays in standing position (35x90 cm) lateral bending X-ravs and traction of 200 N • Special projections: Fergusson a Stagnara • wrist X-ray for bone age measurement (Greulich-Pyle 1959) CT for measurement of apex vertebra rotation Radiological scoliotic measurement COBB - angle of scoliosis and sagittal balance • MOE - evaluation of vertebral rotatio RISSER sign - evaluation of bone age Curve gravity evaluation according to COBB Rotation evaluation according to MOE konvexit a i k onk avi t a I I 1 IN u fl! ( a: 1 1 1 1 1 1 j v 1 1 i .—' 0 1 1 ! 1-H-1 i . 1 1 1 ■ill * I I I I ! I 0 1 1 iTTP 1 1 1 1 1 1 1 1 h4^—J 3 * 1 1 1 i~H—1 RISSER s sig STADIUM 1=2 years before ending of growing peri STADIUM 3 = peak of growing spurt FERGUSON'S projection STAGNARA projection Rotation - vertebra evaluation Th apical vertebra double Th-L curves L apical vertebra Basic terms Apical vertebra Ending vertebr; Neutral vertebr CSVL Stable vertebra 3.2 30 r>r Characteristics of the curves Structural Non-str :ural Curves terminology (according to Cobb angle) Main (weighty rotation) Adjacent (compensatory) Curve structurality • Main - structural Adjacent - structural, non-structural Curve structurality of adjacent curve is important to decide the fusion of adjacent curve in surgical treatment of Non-structural curve ■to' Classification Orientation - right or left convexity Localisation - C,CT,T,TL,L,LS ■ Gravity of curves - according to Cobb angles Etiology Localisation of the curve according to position of the apical vertebra Thoracic: T2- disc Tl 1/12 Upper Th T3 - T5 Lower Th T6 - disc Tll/12 Thoracolumbar: T12-L1 Lumbar: disc L1/2-L Scoliosis - ethiopathogenetic classification Congenital ^^^w Idiopathic..............Z...4/5 80% A ♦ infantile V J ♦ iuvenile ♦ adolescent Neuromuscular ♦ neuropatic ♦ myopatic Neurofibromatosis Secondary ♦ Postural ♦ Tumours ♦ Other syndromas (Marfan, Ehlers-Danlos........) Hysteric Degenerative ■IDIOPATHIC SCOLIOSIS Apparát Lorenzův Uprostřed vyčalounéné železo, nahoře volný kožený řemen, přes který se pacient prohýbá. Ruce za hlavou zvyšují účinek cvičení, kterými se rovná páteř. Unknown etiology, multifactorial Genetic predispositions 8 times more frequent in girls Idiopathic scoliosis Infantile ♦ < 3 years, neonatorum, mostly spontaneous regression, but some times with serious progression Iuvenile ♦ Age of 3 y. - puberty start (10 y.) Adolescent ♦ From puberty start (10 -12 y.) - up to puberty end Classification according to the curve gravity Up to 10 ° -observation 11-20 ° observation -physiotherapy, 20-40 -physiotherapy, bracin More than 40 ° -surgical treatment Conservative therapy Pi Bi hysiotherapy race Brace characteristics: maximally effective active and pasive curve correction lite easily slip-over without chest compression Effective forces distraction derotation poini sysiexr. Three-point principle □ □ □ Physiotherapy in brace • body posture muscle without brace swimming - hippotherapy - excercises according to Vojta (limited effect) and Schrott « Breathing — deep breathing - special bottles - derotation breathing Surgical therapy King classification 1 2 3 4 5 6 Main -=y=- V struct. <^)> V non-struct. Lenke Classification Lumbar Spine Modifier A (No to Minimal Curve) Curve Type (1-6) B (Moderate Curve) C (Large Curve) Possible Sagittal structural criteria (To determine specific curve type) Type I (M.i. I In. I« ii NmmI Type 2 lIKi.Mc T Wirk j 1 1 JA* I ... r f PT ♦ TL KyptWM Kyptotu Kyptoui TL Type 4 rtrtptt Major) \ 4\ P 4B Type 5 ,1LI i <10° T5-12 sagittal alignment modifier: -, N, or N: 10-40° + :>40° Therapeutic planning Methods of correction Adolescent scoliosis Definitive treatment Segmental deliberation (posterior, anterior) Curve instrumentation Stabilisatio Fusion Preoperative planning Posterior approach Anterior approach Combined approach ♦ One-session ♦ Two-sessions Posterior approach One or two curves stabilisation Hyperkyphosis Neuromuscular curves Anterior approach Stabilisation of one curve only Extent of instrumentation Posterior approach ♦ Neutral - neutral vertebra ■ Anterior approach - saving 1-3 segments ♦ Ending - ending vertebra Post Types of surgery r £Lp pTOclCh -spine only -spine and pelvis instrumentation ■ approach -transthoracic -transthoracoretroperitoneal -retroperitoneal -thoracoscopic j C orn bin e cipproach -anterior release + posterior instrumentation -anterior + posterior instrumentation Indication for posterior approach According to Lenke Classification ^Posterior approach - Rigid curves - Double curves - Long curve - Severe curves - Curves with hyperkyphosis > Anterior approach - Simple thoracic curves - Thoracolumbar curves - Flexible curves - Curves with hypokyphosis POSTERIOR APPROACH Types of instrumentation distractive -Harrington segmental -SSE Evolution -USS -Miami-Moss -ISOLA HRI distraction correction method ideal posterior fusion postoperative plaster neccessity HRI - 2 paralel rods HRI + DTT Segmental instrumentation - contemporary method -transpedicular fixation, without postoperative transpedicular pedicular hoo Joint resection Posterior elements decortication Posterolateral fusion Lenke 1 - lower thoracic Juvenile scoliosis Distraction method - one rod Posterior approach Repetitive re-distractions up to growth end Growing rods system - (2 rods) 3 vertebrae fixation, 2 upper and 2 lower curve vertebrae - free ro fixation ■ Repetitive distractions HRI - distraction + definitive surgery ANTERIOR APPROACH ADVANTAGES OF ANTERIOR INSTRUMENTATION Significant derotation Shorter fusion Lordotisation Kyphotisatio Minor blood loss Minor surgical complications TTRP approach Implantation of screws and rod Combined approach in rigid curves 1. Anterior release from minithoracotomy 2. Facultative traction 3. Posterior stabilisation and fusion Rigid curve Lenke 3 Halo traction Physiotherapy and wheelchair 6 months postoperatively Congenital scoliosis Etiologic classification of congenital scoliosis 1. defects of formation -wedge vertebra -hemivertebra 2. defects of segmentation -unilateral failure (unsegme -bilateral failure 3. comb Defects of segmentation anterior ^kyphosis posteriory lordosis RfcStl lateral ^scoliosis h(SB posterolateral Olordoscoliosis anterolaterals kyphoscoliosis complete Defects of formation • anterior lz^kyphosis • posterior iz^> lordosis • lateral lz^> scoliosis • anterolateral lz^kyphoscoliosis • anterior central defect Combine ailure Hemivertebra + unilateral bar Nonsegmented hemivertebra Hemivertebra =the most common failure fully segmented semisegmented nonsegmented Risk of severe scoliosis Evaluation of congenita scoliosis anamnesis (personal and familly) physical evaluation neurological evaluation spinal imaging methods (x-ray,CT,MRi) echocardioqram renal ultrasound ZEPŘEDU Imaging methods Magnetic resonance imaging (MRI) Treatment possibilities conservative treatment • observation • casting and bracing surgical treatment • simple bony fusion • hemiepiphyseodesis • complete posterior • combined a/p • posterior instrumentation • hemivertebrectomy • combined a/p surgery • posterior only surger Observation Indication: Follow up: - - small curves <20° - curves at low risk of progression -nonsegmented hemivertebra -bilateral defects of segmentation - curves <40°at the end of an adolescent age clinical examination every half year follow-up X-ray once per year up to growth competition FU X-ray every five years in adults Progression over 25 bracing or surgery Bracing Indication: - curves 20°-40° - curves at low risk of progression -semisegmented hemivertebra - control ing of secondary curves in growth period Progression over 40 surgery 2 main surgical techniques used today Simple bony fusion Arrest of curve progression (without direct correction) -in small curves -in earlv detection Hemivertebrectomy with instrumentation Correction of scoliotic curve -in greater curves -in supposed a1™* ression Simple bony fusion Indication: - hemivertebra without kyphosis - short curvature < 5 vertebrae - curvature < 50° Technique: - bilateral bone desis - unilateral bone desis - hemiepiphyseodesis (convex side) - posterior, anterior or combined Unilateral fusion growth arrest on convex si< allow growth on concave side Simple bony fusion Postoperative care Plaster cast: first 6-12 months Bracing: till the growth ending clinical examination every half year follow-up X-ray once per year up to growth completition Hemivertebrectomy using combined a/p surgical approach with instrumentation stabilization Associated rib cage deformities Absented ribs Fused ribs Vertical Expandable Prosthetic Titanium Rib (VEPTR) The main factors of quality treatment results: -early detection -good timing -choosing of adequate surgical treatment type Neuromuscular scoliosis Neuromuscular scoliosis the 3rd main scoliotic deformity zx'rzhzivzi pr'ogi'ZEiziOf) (272/1 afr^r maiu/J2J wzigh'fy dzrorn\Vrizz n^üCJüizd wrfh psJvjc ci/jd hip dzfor'u\\~\\zz - cardiopulmonal rinar pressure sores osteopenia Neuromuscular scoliosis Sitting instability Standing instability Etiologic classification of the spinal neuromuscular deformities .neuropathic -affection of the upper motoric neuron -cerebral palsy -Spinocerebellar degeneration (Friedreich, Charcot-Marie-Tooth, Roussy-Levy) -syringomyelia -spinal tumours -spinal trauma -affection of the lower motor 'muro'n -poliomyelitis -spinal muscular atrophy (Werdnig-Hoffmann) -paralytic myelomeningocele myopathic artroqryphosis muscular dystrophy (Duchenne) Neuromuscular scoliosis long unilateral curve kyphoscoliosis lumbar hyperlordosis pelvic and hip deformities 1. Spastic forms paralytic curves Pelvic deformities 1.structural - in spinal deformities 2. functional in muscle imbalances Pelvic deformities Posterior tilt Anterior tilt Pelvic rotatio p OS TE RIOR TILT POSTERIOR TILT Hyperactivity of hip extensors Hamstrings shortening Weakeness of lower back extensors 1 •Decreasing of lumbar lordosis • Lumbar spine flexion ANTERIOR TILT ANTERIOR TILT Shortening of lower back extensors Weakness of trunk muscles Shortening of iliotibial tractus Shortening of hip extensors Increasing of lumbar lordosis PELVIC OBLIQUITY PELVIC OBLIQUITY Unbalanced trunk Lumbar scoliosis Hip dislocation Muscle imbalance: •Hip adductors imbalance •Hip abductors weakness 4 PELVIC ROTATION PELVIC ROTATION Often associated with scoliosis Dislocated hip located in posterior side of rotation WINDBLOW HIP DEFORMITY 1st hip: Flexion+abduction+external rotation 2nd hip Adduction+internal rotation Hip dislocation Pelvic obliquity and rotation Scoliosis Different leg lenght Therapy of the neuromuscular spinal deformities 1. conservative disadvantages: -low ef ect -poor tolerance of the orthosis -worsening of the cardiopulmonal functions -pressure sores 2. surgical indications: -collapse and instability of the sp progressivity in cardiopulmonal d back pain tendence to pressure sores ine dysfunctions Surgical therapy doesn't solve the primary affection improving the secondary dysfunctions Main aims of the surgical therapy: - prevention of the deformity progression - correction of the deformity - improving of the sitting and standing stability - compensation of the pelvic obliquity - improving of the cardiopulmonal functions Combination of the surgical techniaues_ LUQUE = segmental spinal sublaminar instrumentation with translation forces i tran elvic stabilisation Luque spinal segmental _instrumentation good and safe correction stable instrumentation allows the release of the orthosis possibility of the extending to the pelvis Galveston pelvic stabilization foam complications in instrumentation Incorrect implantation of the rod to the pelvis Dislocation of the upper instrumentation part Contemporary treatment transpedicular fixation Other scoliosis Neurofibromatosis Neurofibromatosis „cafe au lait" Neurofibromatosis Nov.P. 1.6.981CH11 Sharp curves High rate of pseudoarthrosis Reexoloration of fusion Scoliosis in other syndromas Secondary curves Postural Inflamations Tumours Hysteria Degenerative Degenerative scoliosis Complications of surgical therap Neurological complications s perioperative - implantation of instruments overcorrectio - mechanical (spinal cord distraction) vascular Cast syndroma - vascular duodenal compression S acute (postop., plaster) v chronical (Wilke syndroma) presion in third part between Duodenal a. mesent. sup. and aorta with partial duodenal obstruction Therapy of cast syndroma S intravenous nutrition S nasogastric drain left side body position (side to side duodenojejunoanastomosis) Later complications ✓ Pseudoarthrosis (loss of correction, pain, loosening of instrumentation) Bending of fusion during growth period Fracture in fusion Infection complications S superficial ep unction, antibiotics / surgical revision, drainage Possible postoperative fixations . Milwaukee brace 2. Plaster cast 3. Orthosis Halo - cast C-Th junction Pressure sores in plaster cast ^ superficial - conservative treatment * deep - surgical treatment - excision, suture Prevention - regular skin care Skin observation scopic defects Red colour of skin Oedema and secretion DEFORMITIES in SAGITTAL ANE Etiological classification • Postural • M. Scheuermann • Congenital • Neuromuscular • in myelomeningocele Traumatic • After surgical treatment Hypo - Hyper kyphosis normal range T5 - T12 = 20°- 40 M.Scheuermann kyphosis dorsalis juvenilis, adolescent kyphosis Vertebral plates incongruentio Intervetebral spaces decreasing Wedge vertebral deformities over 5° Kyphosis over 40° Therapy Physiotherapy Milwaukee brace Surgical treatment