Spinal deformities OO- fysio páteř1 OO- páteř fysio2 Physiological curves of the spine Sagital level Cervical lordosis Thoracis kyphosis Lumbar lordosis Sacral kyphosis Frontal level Skolioza Th Th-L Skolioza rtg Th-L Scoliosis is a deformity in frontal level in sagital level and in transversal level Skolioza skelet 1 Scoliosis is 3D deformity concave convex Skolioza deformita žebra convex concave § frontal level – scoliosis § sagital level – hypo, hyperkyphosis § transversal level – rotation, torsion Ø rib prominence Ø proc. spinosus tilted to concave side Ø narrowing of spinal canal Ø Ø Ø 12 Structural curve - no flexibility - based on structural changes Nonstructural curve - is flexible - nonbased on structural changes Skolioza Th Th-L Curve Structural curve Structural and nonsctructural curve Main curve - occurs earlier - structural - more serious Compensated curve Above and bellow main curve Compensates stability of the trunk Later on changes into structural one Skolioza Th Th-L Curves Skolioza dekomp Compensated Decompensated Scoliosis Trunk compensated/ decompensated Skolioza Th Th-L Thorakální Thorakolumbální Cervical Cervicothoracal Thoracal Thoracolumbar Lumbar Lumbosacral Curves Clinical examination §Compensation of the trunk §Level of shoulders §Asymetry of the waist §Position of the pelvis §Flexibility of curves §Gibus in flexion §Others: laxity, sexual development, lenght of extremities •Functional examination of lungs- spirometry 05 Compensation of the trunk 06 Level of shoulders 02 Gibus (hump) in flexion •Výška ramen Gibus Asymetrie tajle Dekompenzace trupu 03 Sagital balance Frontal balance Neurofibromatosis „café au lait“ X- ray examination •Long films 30x90 cm •AP, lateral, in bending , in distraction •Check up in 6 months •Cobb angle •Skeletal development • Skolioza schéma Cobb angle 07 Skolioza měření rotace Rotation of vertebrae- pedicles Skolioza Risser Risser sign 0 no apophysis 1 25% 2 50% 3 75 % 4 100 % 5 Fusion with iliac bone Classification §Orientation – right, left §Localisation, C, CT, T, TL, L, LS §Severity of the curve- Cobb angle §Etiology § § § Classification • Structural • Congenital • Idiopathic (80%) – infantile, juvenile, adolescent • Neuromuscular – neuropatic, myopatic • In neurofibromtosis • Secondary scoliosis Marfan sy, Ehlers-Danlos sy • Degenerative scoliosis • Nonstructural • Postural • Hysteric • in other morbidities – tumor, infection • Idiopathic scoliosis §Etiology unknown, multifactorial §Genetic background §Prevalence in girls 1,5 more often §Progression- in girls 8 times more § Treatment Up 10° - no scoliosis 10-20° - exercise therapy, follow up 20 - 40° - orthesis, exercise therapy Above 40° - surgery Scoliosis in adults •Progresion of the curvature –low, in Cobb angle less than 30° –often, in Cobb angle over 50 ° in thoracis – and over 30° in lumbar spine •Limited breathing in thoracic curves over 90° •Back pain Idiopatic scoliosis §Infantile –Up to 3 years of age – usualy spontaneous resolving (90%), – in less cases severe progression §Juvenile –3 years of age – to onset of puberty §Adolescent –Puberty - the end of growth Exercise therapy •Exercise, correct posture •Pelvic alignment •Strenghtening of trunk and abdominal muscles •Breathing •High level activities •Follow up in 6 moths regime Exercise + bracing •To prevent progression •Effective only in low curves •Over 45° no effect • •Indication: in growing children with flexible curve • •Curves are progressive in fast growing periods • •To wear 23 hours per day, up to the end of growth (16-17 years) gradually to wear less hours per day. •Principles of the brace • distraction • derotation • three point system 4 3 09 10 Milwaukee orthesis – curves T6 and above dávka 023 dávka 022 davka 024 TLSO orthesis - curves in Th7 and lower •Exercise in a brace • stretching • correct posture • exercise using balls • activation in sports 03 04 Pic00014 Pic00013 KIF_1228 KIF_1223 02 01 • Withount a brace - swimming - hippotherapy 12 • Breathing therapy - deep breathing - bottles - derotation breathing 01 Surgery •Indication: –Above 40° in fast progression –Above 50° in all •Principles: –Correction of the curve (distractions, derotation, – translation of vertebrae) –Repeated distraction in younger patients (HRI) –growing rods –spondylodesis –Postoperative bracing – • • – – •The aim of surgery: • –Correction of the curve –Prevent progression –Influence worsening of pulmonar function – (cor kyphoscolioticum- ischemic heart disease) –Improve situation for better muscle function –Prevent degenerative changes ( spondylosis and spondylarthrosis) –Cosmetic effect Dorsal approach 012 skeletizace, resekce kloubů, dekortikace zadních elementů 016 Transpedikulární šrouby či pedikulární háčky 081 Dokončení, propojení, štěpy Juvenile scoliosis HRI + repeated disctraction, fusion later on 03 02 01 Dorsal approach 6146rtg 6137 6164 6153rtg2 Congenital scoliosis • from the childbirth • asymetric growth of the spine • more often fast progression Etiology: 1. Disturbance of the form 2. Disturbance of segmentation 3. Combined disturbance • Management: surgery • fusion • osteotomy + fusion • hemivertebrectomy Páteř- kong skolioza Disturbance of the form Skolioza kong Wedge vertebra Hemivertebra Páteř- kong skoliosa 1 Hemivertebra Disturbance of segmentation Skolioza kong Nonsegmented bone rod Bone block Combined disturbance Páteř- kong skoliosa 2 Neuromuscular scoliosis Neuropatic: recebral palsy polio, spinal dysraphism Myopatic: muscles dystrophy, arthrogryphosis „ paralytic scoliosis“ Long, severe curves Therapy: Surgery, long fusion 19 20 • short curve • atypical shape of vetebrae severe rotation • changes of ribs Typical: Progressive Surgery is necessary Atypical: Progression as in idiopatic scoliosis- treatment the same Scoliosis in neurofibromatosis Páteř- neurofibrom skolioza Páteř- neurofibrom Secondary scoliosis • Osteogenesis imperfecta • Spondyloepiphyseal dysplasia • Diastrophic nanism • Rickets • Marfan syndrom • TB • Injuries • Degenerative scoliosis 18 19 Degenerative scoliosis Nonstructural scoliosis • Postural • In sciatica • Tumors • Spondylodiscitis • Leg length discrepancy • Contractures in hip region • Hysterical Pathological kyphosis • Congenial • Neuromuscular • Juvenile kyphosis • Others • congenital deformity (achondroplasia, mucopolysacharidosis) • postraumatic ( + after laminectomy) • after spondylodiscitis, TB) • in tumors • in osteoporosis, osteomalatia •Postural kyphosis • 0,5 - 8 % of population • boys more often • age 12-18 years • Etiology- idiopatic, multifactorial • distal thoracic region more often Juvenile kyphosis 02 • Increased thoracic kyphosis above 40° • Fixed kyphosis (hyperextension test) • Pain • Limited movements • Limited dynamics of the spine • Progression of degenerative changes Skolioza m Juvenile kyphosis D:\archiv\obrazky_\doktori\muller\rehab_Scheuermann\887.JPG X ray findings: • kyphosis above 40° • Irregularities of end plates • Schmorl´s nodes • Narrowing of intervertebral disc spaces • Wedge deformity above 5° at least in 3 vetebrae Juvenile kyphosis D:\01.jpg Páteř Scheuermann rtg1 Páteř Scheuermann rtg1 Stages •I. stage - florid (9-12 years, flexible, round back, • painful spine, muscle changes) • •II. stage- deformity (13-16 years, fixed • advanced X ray changes) • •III. stage- consequences (chronic back pain) Juvenile kyphosis Therapy: • Conservative – exercise therapy - orthesis - plaster of Paris brace, later on orthesis + exercise - in florid stage- no sports, no weightbearing - NSAD, analgetics, myorelaxans • Surgery + bracing + exercise Juvenile kyphosis Etiology • Disturbance of the form • Disturbance of segmentation • Combined disturbance Therapy: • to prevent progression • Surgery in progressive curves • Spondylodesis – fusion + bracing till the end of the growth • anterior osteotomy with correction of the curve + posterior fusion with instrumentation Congenital kyphosis Páteř- op Postural kyphosis • in muscle imbalance lack of exercise, lack of sports sedentary way of life • weak trunk and abdominal muscles increased lumbar lordosis and thoracic kyphosis Management: • regular exercise of muscles- trunk, abdominal .. • sports activities • adherence to active life • profesional fysiotherapy