Scoliosis Prýmek M., Repko M., Filipovič M., Leznar M. Department of Orthopedic Surgery – Faculty of Medicine – Masaryk University Ass. Martin Prýmek 01.jpg • • F:\RTG\39.jpg F:\RTG\41.jpg F:\RTG\42.jpg Scoliosis = 3 D deformity Frontální rovina Sagitální rovina Axiální rovina •Shoulder height disbalance Gibbus – paravertebral prominence Waist asymetry Trunk decompensation - frontal plane , C7 plumb line • • F:\RTG\39.jpg F:\RTG\42.jpg Bending forward! = Adams test SAGITTAL aspect 02 D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\DSC_0390.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\export--62203558.jp g D:\archiv\2003\0303\3103\01.jpg HYPOkyphosis HYPERkyphosis TRANSVERSE aspect DSC_0158 Scoliotic patient EVALUATION Adam‘s test normal scoliosis Plumb line X-RAY AP lateral bending D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219557.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219561.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219556.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219553.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219555.jpg D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Wagnerová_Karolína_2005\dlouhy format AP + B,,,_2547616\export--76001879.jpg D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Wagnerová_Karolína_2005\dlouhy format AP + B,,,_2547616\export--76001883.jpg traction COBB‘s angle C:\Users\martin\Desktop\foto skripta\foto NM skol\7.8.JPG Descriptive terminology •Apical vertebra •End vertebraKoncový ratel •Neutral vertebra •CSVL •Stabile vertebra • • Therapeutic scheme observe Brace surgery 0-20° 20-40° >40° > Physiotherapy F_038_07_MurtGP4e_000218.jpg COBB 10+5 12+7 14+3 16+5 29+4 Natural evolition of untreated juvenile idiopathic scoliosis 45° 50° 61° 68° 73° Deformity worsening • • •68% pts had progresion even in adult age ! • (Weinstein et al) •Thoracic curves - 1 dg./year •Thoracolumbar curves - 0,5 dg./year •Lumbar curves - 0,24 dg./year G:\adult_scoliosis_cause02.jpg Sever complication of untreated scoliosis in childhood = Degenerative changes and cardiopulmonal insuficiency 2015 2018 35 let 32 let Risks of curve progression •Progressive oppression of intra-abdominal organs •Heart + Lungs •Indigestion •Degeneration of spine structures •Intervertebral joints •Intervertebral disc-> •production of osteophytes with possible nerve compression ! Goals of scoliosis surgery in childhood •Stop deformity progression •Correction of deformity •Improvement of cardiopulmonary functions •Prevention of degenerative spine changes Scoliosis surgery in adult age •Higher surgery risks with lower success rate of deformity correction •Often associated with nerve impairment •Difficult tolerance of corrected torso and spine position •Slow postoperative convalescence (pain) - long-term rehabilitation care is required • Surgical risks in general •From GA •Venous thrombosis •Pulmonary embolism •Nausea, vomiting, rhythm disorders, etc. •Surgical •Surgical wound infection •ATB therapy •Bleedig •blood transfusion • • Surgical risks specific for scoliosis surgery •Increased postoperative pain due to stretching of shortened muscles - in each patient •Paralysis due to surgery •For thoracic and lumbar curves it refers to the lower limbs Very rare complication, but very serious as a result. • MEP – motor evoked potentials (SSEP) •Monitoring of nervous system functionality during surgery •It enables immediate reaction to the problem and thus minimizes the risk of permanent nervous disability MEP – motor evoked potentials (SSEP) SEP a MEP 168.JPG 003.JPG Method of surgical scoliosis treatment. •Transpedicular screws •Bended rods •Bone grafts (autografts, alografts) • = INTERVERTEBRAL FUSION Výřez obrazovky DSC_0023 DSC_0128 Základní pojmy popisné •Apical vertebra •End vertebraKoncový ratel •Neutral vertebra •CSVL •Stabile vertebra • • •Idiopathic……..............4/5 80% •infantile •juvenile •adolescent •Neuromuscular •neuropathic •myopathic •Syndromic - Neurofibromatosis •Secondary •postural •tumors •Other syndromes(Marfan, Ehlers-Danlos……..) •Histerical •Degenerative • Scoliosis types due to ethiology Scoliosis types due to ethiology Deformity type Age •Idiopathic •Congenital •Neuromuscular •Infantile < 3 y •Juvenile 4-10 y •Adolescent 11-17 y •Adult > 17 y • • F:\RTG\39.jpg F:\RTG\41.jpg F:\RTG\42.jpg Coronal plane Sagittal plane Transverse plane SCOLIOSIS = 3 dimensional deformity COBB‘s angle C:\Users\martin\Desktop\foto skripta\foto NM skol\7.8.JPG Essentially distinguish between: Structural curve Non-structural curve Výřez obrazovky 49° 34° D:\Archiv\Archiv_RTG\Skolioza\2012_Skolioza_klinické_foto\Mrázová_Michaela_1998\01-2.7.2012\export- -35105152.jpg 17° D:\Archiv\Archiv_RTG\Skolioza\2012_Skolioza_klinické_foto\Mrázová_Michaela_1998\01-2.7.2012\export- -35105151.jpg 27° bending >25° bending <25° EVOLUTION in scoliotic classifications KING-MOE LENKE 3D ??? 1D frontal 2D frontal+sagittal LENKE‘s classification •Curve type lenke__web_Main.jpg •Lumbar spine modifier •Thoracic sagittal profile LENKE‘s classification •Curve type lenke__web_Main.jpg Obr.4a.gif Lenke class.gif Lenke class.gif Lenke‘s classification curve types • • 1 2 3 4 5 6 8a 8b 8c 9a 9b 9c LENKE‘s classification lenke__web_Main.jpg •Lumbar spine modifier Lenke class.gif • • B C A 07 10 Lenke‘s classification lumbar parameter LENKE‘s classification lenke__web_Main.jpg Lenke class.gif •Thoracic sagittal profile • • + N - < 10° 10° - 40° > 40° Lenke‘s classification sagittal parameter • • > 40° Lenke‘s classification EXAMPLES D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\export--74247125.jp g Lenke 1 Girl 13+9 45° D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\export--62203558.jp g D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\export--62203556.jp g D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\DSC_0387.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\DSC_0390.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Oujezská_Alžběta_1997\DSC_0388.JPG +6° Lenke 1A- type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 1 Non-Structural Structural (Major) Non-Structural MT (Main Thoracic) Lenke 2 Girl 14+1 46° 50° D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Pohanková_Alžběta_1998_idiop\DSC_0012.JPG D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Pohanková_Alžběta_1998_idiop\DSC_0014.JPG D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Pohanková_Alžběta_1998_idiop\DSC_0018.JPG D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Pohanková_Alžběta_1998_idiop\DSC_0016.JPG type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 2 Structural Structural (Major) Non-Structural DT (Double Thoracic) Lenke 3 Girl 14+2 72° type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 3 Non-Structural Structural (Major) Structural DM (Double Major) 64° D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Faloutová_Veronika_2001_idiop\DSC_0156.JP G D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Faloutová_Veronika_2001_idiop\DSC_0158.JP G D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Faloutová_Veronika_2001_idiop\DSC_0159.JP G D:\Archiv\Archiv_RTG\Skolioza\2015_Skolioza_klinické_foto\Faloutová_Veronika_2001_idiop\DSC_0161.JP G D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219557.jpg Lenke 4 Girl 12+9 43° type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 4 Structural Structural (Major) Structural (Major) TM (Triple Major) 47° D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219561.jpg 51° D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219556.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219553.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\TH-uklony do stran,L-uklony do stran,dlouhy format AP + B,_1751548\export--52219555.jpg D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\DSC_0010.JPG D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\DSC_0011.JPG D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\DSC_0016.JPG D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\DSC_0013.JPG D:\Archiv\Archiv_RTG\Skolioza\2013_Skolioza_klinické_foto\Soviarová_Eliška_2000\DSC_0014.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Švárová_Kateřina_2001\export--69451849.jp g Lenke 5 Girl 12+5 type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 4 Non-Structural Non-Structural Structural (Major) TL/T (Thoracolumbar/Lumbar) 56° D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Švárová_Kateřina_2001\export--69451863.jp g D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Švárová_Kateřina_2001\export--59860535.jp g D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Švárová_Kateřina_2001\DSC_0420.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Švárová_Kateřina_2001\DSC_0426.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\dlouhy format AP + B,,,_2327968\export--69791731.jpg Lenke 6 Girl 16+9 type Proximal thoracic Main thoracic Thoracolumbar/lumbar Description 4 Non-Structural Structural Structural (Major) TL/T-MT (Thoracolumbar/Lumbar-Main Thoracic) 114° 96° D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\dlouhy format AP + B,,,_2327968\export--69791735.jpg D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\DSC_0045.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\DSC_0046.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\DSC_0048.JPG D:\Archiv\Archiv_RTG\Skolioza\2014_Skolioza_klinické_foto\Michelová_Beáta_1998\DSC_0050.JPG Therapeutic chart observation bracing surgery 0-20° 20-40° >40° > PHYSIOTHERAPY F_038_07_MurtGP4e_000218.jpg COBB Non-operative treatment physiotherapy casting bracing CASTING Indication: INFANTILE scoliosis Applying under the general anesthesia Changing each and every 2 month P5160713 images-8.jpeg BRACING davka 024 dávka 023 dávka 022 C:\Documents and Settings\Slechta\Dokumenty\Obrázky\trupové ortézy\22.jpg BRACING Indication for bracing: progressive scoliosis poor or no casting toleration unable to undergo surgery C:\Documents and Settings\Slechta\Dokumenty\Obrázky\trupové ortézy\22.jpg 01 3D scoliotic correction F:\RTG\39.jpg F:\RTG\41.jpg F:\RTG\42.jpg vertebral-derotation.jpg Corrective methods skoliozaDDM 024 5-derotation 3,4-translation 2-compression 1-distraction DSC_0461.JPG EVOLUTION in corrective maneuvers DISTRACTION TRANSLATION VCM Rod Roduction HarringtonRods25.gif DSC_0116 DSC_1049.JPG HarringtonRods25.gif 1D frontal 1D frontal 2D frontal, axial 3D frontal, axial, sagittal DSC_0439.JPG EVOLUTION in corrective maneuvers BRACING 1748-7161-5-1-s12.jpg 1748-7161-5-1-s4.jpg Source: Rigo et al, Scoliosis 2010 1748-7161-5-1-s12.jpg 2013Jul_4-02.jpg EVOLUTION in corrective maneuvers BRACING Advantages: •Surgery elimination Disadvantages: •Poor toleration •Lung function decreasing •Muscle weaking Problems: •HYPOKYPHOSIS •POOR DEROTATION C:\Documents and Settings\Slechta\Dokumenty\Obrázky\trupové ortézy\22.jpg IMG_5272.jpg IMG_5273.PNG IMG_5272.jpg HarringtonRods25.gif DISTRACTION EVOLUTION in corrective maneuvers hypokyphosis EVOLUTION in corrective maneuvers DISTRACTION Advantages: •Simple implantation •Possibility of spine growth •Miniinvasive approach Disadvantages: •Uniplanar correction (frontal) •High rate of complications 08 06 Problems: •HYPOKYPHOSIS •NO DEROTATION IMG_5272.jpg IMG_5273.PNG IMG_5272.jpg TRANSLATION EVOLUTION in corrective maneuvers hypokyphosis DSC_0130.JPG rod derotation DSC_0116 EVOLUTION in corrective maneuvers TRANSLATION Advantages: •Good frontal correction Disadvantages: •Uniplanar correction (frontal) Problems: •HYPOKYPHOSIS •NO DEROTATION IMG_5272.jpg VCM VERTEBRAL COLUMN MANIPULATION EVOLUTION in corrective maneuvers hypokyphosis vertebral-derotation2.jpg F:\RTG\42.jpg Derotation WHY derotation? •3D scoliotic correction •Correction of Rib Hump prominence •Secondary curve correction in selective fusion Balanced spine Transpedicular screw constructs •Allows effective derotation of single vertebra Derotation instruments •Allows safe and effective derotation of single vertebra as well as the whole apical area. EVOLUTION in corrective maneuvers VCM Vertebral column manipulation Advantages: •Good frontal and axial correction Disadvantage: •little too forced isolated technique spinal-adjustment-m.jpg Problem: •HYPOKYPHOSIS EVOLUTION in corrective maneuvers RESULT of most correction maneuvers •HYPOKYPHOSIS •ABSENCE or RESTRICTIVE DEROTATION DEROTATION Transversal plane Scoliosis Spiral concept 3D geometrical changes • • IMG_2711a IMG_2711a DSC_0327.JPG Surgical posterior approach DSC_0331.JPG level checking export--79398112.jpg Probe - pedikle finding DSC_0332.JPG Sound - pedikle hole checking - screw length measuring DSC_0333.JPG Screwdriver - screw insertion DSC_0334.JPG Screwdriver - screw insertion DSC_0338.JPG Chisel – facet resection DSC_0339.JPG DSC_0340.JPG DSC_0135.JPG DSC_0137.JPG DSC_0138.JPG IMG_1565.PNG Chisel – facet resection DSC_0140.JPG Luer – cortex resection DSC_0342.JPG DSC_0376.JPG DSC_0400.JPG export--79398113.jpg DSC_0404.JPG DSC_0407.JPG DSC_0406.JPG DSC_0409.JPG DSC_0412.JPG DSC_0413.JPG DSC_0413.JPG DSC_0415.JPG DSC_0418.JPG DSC_0432.JPG DSC_0433.JPG DSC_0436.JPG DSC_0439.JPG DSC_0443.JPG DSC_0444.JPG DSC_0446.JPG DSC_0459.JPG DSC_0461.JPG DSC_0467.JPG DSC_0487.JPG export--79398115.jpg export--79398113.jpg DSC_0510.JPG DSC_0512.JPG Nonfusion surgery methods • dual.jpg dual 2.jpg VEPTR = vertical expandable prosthetic titanium rib •Indikace: kong. def. + thoracic insufficiency syndrom + kostní nezralost •Cíl: zvětšení objemu hrudníku + korekce deformity •Nutné opakované redistrakce veptr.jpg Magnetické tyče (Magnetic rods) MAGEC_ERC_Big.jpg MAGEC.jpg Screen Clipping Growth Guided System •Deformity correction + growth enabled •Fusion of the apex of the curve •The rest of spine grows guided along the rods • Shilla sroub.jpg • C:\Users\martin\FOTO growing rods\Arnoštová_Lucie_2000_SOCORE\DSC_0034.JPG C:\Users\martin\FOTO growing rods\Arnoštová_Lucie_2000_SOCORE\DSC_0040.JPG C:\Users\martin\FOTO growing rods\Arnoštová_Lucie_2000_SOCORE\DSC_0071.JPG Výřez obrazovky Výřez obrazovky Výřez obrazovky 3+9 3+10 5+10 7+5 Výřez obrazovky 10 +9 poop 13+8 15+1 GGS requires definitive fusion ! •Pts need 2 surgeries at least ! •Convertion to definitive fusion after skeletal maturity. Scoliosis types due to ethiology Deformity type Age •Idiopathic •Congenital •Neuromuscular •Infantile < 3 y •Juvenile 4-10 y •Adolescent 11-17 y •Adult > 17 y Congenital scoliosis •Congenital Scoliosis- inborn spine deformity due to imperfect formation of vertebrae and their association. •Hard to predict development and deformity progression … Congenital scoliosis •deformity occurs during the first 6 weeks of embryonic development without hereditary burden, it is not hereditary •wide diversity of severity of disability •dg. newborns / toddlers, can occur at any time during growth • • CONGENITAL scoliosis Failure of FORMATION E:\neuromus_skol\3.jpg Hemivertebra Failure of SEGMENTATION E:\neuromus_skol\2.jpg Unsegmented bar COMBINED failure E:\neuromus_skol\7.jpg Congenital scoliosis •Failure of SEGMENTATION- failure of the connection of one or more vertebrae on one side •Failure of FORMATION- most often, disorder of vertebra formation, shape anomalies •COMBINED failure Failure of segmentation •Anterior : •Vertebrae are held together due to unsegmented bar a , but they grow normaly all the posterior structures •-> kyphosis ! •„anterior unsegmented bar“ • • 01 Failure of segmentation •Posterior unsegmented bar – fusion of intervertebral joints and laminas •-> lordotization • • • C:\Users\Robin\Pictures\2014-11-03\012.JPG Failure of segmentation •Unilateral unsegmented bar leads to sever scoliosis deofrmity • • • C:\Users\Robin\Pictures\2014-11-03\014.JPG Failure of segmentation •Usualy asymptomatic •Can lead to relative shortening of spine • •„block vertebra“ – iv disc is missing 4 Failure of formation •anterior •Could affect just part of vertebra / all structures •Solitary or multiple changes •„posterior hemivertebra“ •-> kyphosis • •posterior – much less common •- > lordosis • • 5 Failure of formation •Lateral •Hemivertebra •-> scoliosis deformity • •Important one ! • • • C:\Users\Robin\Pictures\2014-11-03\016.JPG Failure of formation •Postižení solitární až mnohočetné • •Postižení sousedních obratlů nebo •v různých úsecích páteře • C:\Users\Robin\Desktop\lonner2arrow_copy-99.jpg • closed type / neuzavřený poloobratel • • • • • • • • • • bez progrese / progrese deformity C:\Users\Robin\Desktop\002.JPG Hemivertebra types Failure of formation •Aterior central defect •The two parts of vert. are not connected together • •„butterfly vertebra“ • •- According to severity of the anterior defect can lead to kyphosis or is completely asymptomatic • • 6 Obsah obrázku modrá Popis byl vytvořen automaticky Combined failure •- Very common -Multiple changes • -Very individual • •- Hard to predict progression in multiple changes, observation is the key. - • Combined failure 7 9 The highest risk of progression = Fully segmented hemivertebra + contralateral unsegmented bar !! Congenital scoliosis - therapy • • Main rule – STOP the progression ! • Observation – X-ray á 6months • • if there is progression of deformity -> surgery • • fastest growth– frist 5y of age • + adolescent growth spurt • -> highest risk of progression !!! • • • • Hemivertebra Risk of sever scoliosis 2 main used surgical techniques Simple bony fusion Hemivertebrectomy with instrumentation Arrest of curve progression (without direct correction) -in small curves -in early detection Correction of scoliotic curve -in greater curves -in supposed curve progression C:\Documents and Settings\rdcuser\My Documents\obrazky\nastroj.jpg C:\Documents and Settings\rdcuser\My Documents\obrazky\pater_step1.jpg DSC_0065.JPG Surgery of hemivertebra Simple fusion Hemivertebrektomy pater pater_step1 •Small deformities •Blockage of worsening •Without correction possibility •Larger deformities •Curve correction •Prevention of secondary curves • P5241728 P5241745 P5241749 Hemivertebrectomy combined approach P5241757 P5241762 2 3 07 DSC_0004.JPG animace2.gif DSC_0023.JPG DSC_0043.JPG DSC_0065.JPG Hemivertebrektomy posterior approach only The main factors of succesful treatment of congenital scoliosis Conclusion •early detection •good timing •adequate surgical approach Diastematomyelie Výsledek obrázku Výsledek obrázku Skl, Mot Výsledek obrázku Výsledek obrázku pro Tethered cord Výsledek obrázku pro Tethered cord Tethered cord syndrome Výsledek obrázku Výsledek obrázku An external file that holds a picture, illustration, etc. Object name is AJNS-10-226-g002.jpg CT Výsledek obrázku Výsledek obrázku MRI Neuromuscular scoliosis • F:\repko\0163.jpg Scoliosis types due to ethiology Deformity type Age •Idiopathic •Congenital •Neuromuscular •Infantile < 3 y •Juvenile 4-10 y •Adolescent 11-17 y •Adult > 17 y Neuromuscular scoliosis • • - Significant progression (even after growth) • severe deformities • combined with pelvic and hip deformities •high degree of associated dysfunction •cardiopulmonary •urinary • pressure sores • osteoporosis Conservative treatement •1.physiotherapy • • •2.Protsthetic care • •braces • •Sitting support brace in wheelchair • •3.Nursing care • C:\Documents and Settings\rdcuser\My Documents\foto skripta NM skol\foto36.JPG Léčebné postupy 1. Conservative treatement disadvantages : -small effect - Poor orthosis tolerance -negative influence of K-P function with orthosis -decubits 2. surgery indication: -collapse and instability of the spine -deterioration of cardiopulmonary functions by orthosis -back pain - the tendency to pressure sores Neuromuscular spine deformity = complex deformity •Long thoracolumbar dx convex curve •kyphoscoliosis •hyperlordosis •Hip anomaly •Pelvic obliquity F:\repko\0163.jpg Pic00005 Windswept hip Screen Clipping • 4.6.jpg Basic NM scoliosis types SPASTIC FLACCID •brain •cerebellum •Upper motoneuron •Lower motoneuron •Primary myopathy • Obr.6.jpg Paralytic deformities Stiff , rigid deformities 6.3.A.JPG 1. 1. 1. 1. 2.Hypotonic forms paralytic deformities NM spine deformities 6.3.B.JPG 6.3.A.JPG 6.4.A.jpg 6.4.B.jpg 1. 1.Spastic forms 2. 2. 2. Rigid kyfoscoliosis 1. 1. 1. NM spine deformities C:\Documents and Settings\rdcuser\My Documents\foto skripta NM skol\foto11.JPG C:\Documents and Settings\rdcuser\My Documents\foto skripta NM skol\foto12.JPG Sitting instability Standing instability Clinical examination of NM deformities Gibbus prominence meas. Plumb line 7.1.JPG 7.2.JPG 7.3.JPG Correction in traction FLACCID deformity gravity Snímek obrazovky 2017-03-18 v 15.54.55.png Trunk collapse TYPES A. Neuropathic I.upper motoneuron failure •cerebral palsy •spinocerebellar degeneration (Friedrich's Ataxia, CHMT, Roussy-Levy syndrome) •syringomyelie •spinal tumors •spinal cord injury A. Neuropathic II. lower motoneuron failure •Poliomyelitis •other viral myelitis •Injuries •SMA spinal muscular atrophy Werdnig-Hoffman, Kugelberger-Welander B . Myopathic curves •Arthrogryposis (not progressive) •Muscular dystrophy (Duchene, limb-girdle syndrome, •fascioscapulohumeral syndrome) •fiber type disproportion syndrome •congenital hypotonia •dystrophic myotonia SMA Infantile WERDING-HOFFMAN •Most common •Fleet contractures, disability •Often without affecting the inteletctus •Disability of the hips •Scoliosis: paralytic curves, progression Screen Clipping Duchene muscular dystrophy •- absence of dystrophin protein •Muscle biopsy •DNA tests - absence of dystrophin + significant creatine phosphokinase elevae •Poor muscle regeneration •Gradual replacement of muscles by fibrous tissue. Screen Clipping Duchene muscular dystrophy •2– 6y - the first symptoms come, dystrophin deficiency and, as a consequence, dying muscle fibers are beginning to be replaced by ligaments. •problems with walking, during, getting up from a lying or sitting position •pseudohypertrophy of calves •wheelchair •developent of kyphoscoliosis • Výsledek obrázku pro kugelberg welander Therapeutic approach •A. Muscular disbalance of the lower limbs -extension of adductors in DMO B. solution of hip dislocations C. deformity of pelvis and spine Surgical treatement •INDICATION •Paralytic curves collapse and instability of the spine •Progressive deformity •Sitting instability •Impairment of cardiopulmonary functions by orthosis •Back pain •Tendency to pressure ulcers •CONTRAINDICATION •Poor overall internal condition Very low breathing capacity General or local infection Significant non-cooperation of the patient Surgical treatement •Goals •avoiding curve progression improved sitting stability •reduction of back pain •preventing further loss of motor and sensitive functions •Improvement of cardiopulmonary and GIT functions. •Complication •nerve structures injury bleeding and extensive loss organ injury Heart Failure cerebral dysfunction sudden death neurolgical complications infection chronic infection instrumentation failure pseudoarthrosis • Pelvic fixation •Iliac screw •S2AI screw • Galveston Luque Galveston technique 8.15.A.jpg 8.15.B.jpg 8.15.D.jpg 8.15.C.jpg • • • Výřez obrazovky • Výřez obrazovky Výřez obrazovky • Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky • Výřez obrazovky Universal Clamp • CLAMP_03-copie.jpg 13743851.jpg DSC_0108a.jpg clamp-200x380.jpg o • 13666937.jpg 13743851.jpg 13744023.jpg 9119610.jpg NM scoliosis – take home • •Progression after even after skeletal maturity •Numerous comorbidities •Higher peri and postoperative complications •Necessity to include pelvic fixation in pelvic obstruction deformities •The need for post-operative care. • Scoliosis in general-take home message •3D deformity ! •AIS 80% of all deformities •Physiotherapy does not stop progression in AIS ! •Brace from 20°Cobb to stop progression in growing patient •Surgery above 40°Cobb angle 01.jpg