How to do a clinical and radiological workup? SCOLIOSIS Dr Kshi6j Chaudhary MS, DNB, FACS Consultant Spine Surgeon Sir HN Reliance Founda6on Hospital BYL Nair Ch. Hospital & T. N. Medical College Mumbai 1 Key Concept Hyper Hyper Normal ? 20°-40° 0° ? 40°-60° >10°° ?° ?° Abnormal 2 The spine is straight in the coronal plane. No curves. So any lateral deviation > 10 deg is called as scoliosis. In the lateral view, you have normally kyphosis and lordosis, and defining a normal value is a bit tricky. Remember that normal in the lateral view is a RANGE. Scoliosis is NOT a diagnosis 3
Transcript
How to do a clinical and radiological workup?
SCOLIOSIS
Dr Kshi6j Chaudhary MS, DNB, FACS
Consultant Spine Surgeon Sir HN Reliance Founda6on Hospital BYL Nair Ch. Hospital & T. N. Medical College Mumbai
1
Key Concept
HyperHyper
Normal ? 20°-40° 0° ? 40°-60°
>10°°?° ?°Abnormal
2 The spine is straight in the coronal plane. No curves. So any lateral deviation > 10 deg is called as scoliosis. In the lateral view, you have normally kyphosis and lordosis, and defining a normal value is a bit tricky. Remember that normal in the lateral view is a RANGE.
Scoliosis is NOT a diagnosis
3
4 Different etiologies
SkeletalMaturity
Decision
Etiology
History Examination
Imaging Specialist Referrals
Clinical markers Skeletal markers
Do nothing Observe Brace
Surgery
Natural History
Xrays
5 The natural history (whether the curve is going to progress or not as the child grows) depends on these three factors
And the treatment decision as based on the expected natural history of the curve.
Idiopathic Scoliosis is a diagnosis of EXCLUSION
6 Another key concept to remember is that Idiopathic scoliosis (the most common type of scoliosis) is a diagnosis of exclusion.
Growth and Maturity 7 Let’s first talk about Growth and Skeletal maturity. This is extremely important to know if one wants to understand scoliosis.
8 Decrease in growth rate from the massive intrauterine growth. Still the growth rate is very high. Decreases up to age 4-5 and then plateaus. Then pubertal growth spurt. The timing of the growth spurt (peak height velocity) occurs approximately two years earlier in girls than in boys. But Boys continue to grow for a longer time and end up taller.
9
10 By Duval Beaupere (France)Scoliosis progression in two phases. Mathematical relationshipGreater the velocity during the first period sharper will be the rise in the secondEarlier the age at which puberty starts longer will be the second phase. Concept of Point P.Slope P1 and Slope P2.
How to idenBfy Point P ?
11
12 Key Concept-Not all kids will have puberty at a fixed age. -Some are early bloomers and other are late
Child 1Child 2
Child 3Child 4
Child 5
13 Individual growth velocity curves peak at different ages. Also note that those who reach PHV at an early age have a higher peak. Amount of height gained during the spurt is to a considerable degree independent of the amount gained prior to it as growth in puberty is under different hormonal control form the growth before this period.
Average of these curves (dotted line) does not represent the the true growth (it smoothens out the growth spurt.
Peak Height Velocity
14 When the curves are plotted wrt to age at PHV then it makes more sense.
Chronological Age CANNOT be the only parameter
15 So now we know that age cannot be the only parameter to determine onset of puberty.
Maturity Markers
• Menarche • Secondary Sexual Characters
- Breast - Pubic and axillary hair - Genitals - Voice change - Facial hair
16 There are various maturity markers other than age that need to be considered. One should know where to place these markers on the growth curve.
16
:Axillary
17The ages in this chart are skeletal age rather than chronological age. Girls have onset of puberty approximately 2 year earlier.
The onset of puberty in boys and girls corresponds to Tanner 2 stage.
Tanner 2Risser 4
No change in serial height
Closure of triradiate car6lage
Menarche Axillary hair
Risser 1
18 Menarche occurs, on average, 2.6 years after the onset of puberty and 0.5 years after peak height velocityHowever, girls continue to grow (with decreased velocity) for approximately 24 months after menarche
So a child who has had menarche is already past the fastest growth and for her the growth is slowing down.
Tanner 2
Breast budding Appearance of Pubic Hair
(Girls)
Appearance of Pubic Hair (Boys)
19 Tanner grade 2 (the onset of puberty) precedes peak height velocity
In GIRLS - breast budding occurs after onset of pubertyIn BOYS - appearance of pubic hair is before onset of puberty
22 The child or parent may notice it. Or pediatrician may notice during examination.
Deformity
• When was it first no6ced?
• Who noted it?
• Is it progressive?
• What treatment has been taken so far? How long? - Details about old records / X-rays - Bracing? - Prior procedures
23 When was the deformity first noted? (If the onset is younger than 10 years of age, there is more risk of neuraxis abnormalities besides the curve has had more time to progress and may be much larger)
and who noted it? (Curves noted by the family tend to be greater than those noted by the primary care provider or detected through school screening.)
Rapid progression of the curve is suggestive of an non idiopathic cause
PainIdiopathic Scoliosis does not cause pain
24 Go in detailed questioning about the nature of pain.
Does the patient have significant back pain (pain that limits activities, wakes a patient at night, or requires frequent analgesia?
Significant pain increases the likelihood of an nonidiopathic cause!E.g. osteoid osteoma, spondylolysis, spondylolisthesis, Scheuermann kyphosis, syrinx, herniated disc, hydromyelia, tethered cord, intraspinal tumor.
Neurologic Symptoms
Especially when angular kyphosis
Gait problemsLoss of balance
Due to Deformity
Due to Underlying Cause HeadachesNeck painNumbness
ParasthesiasMuscle weakness
B/B problems
25 Uncommon for scoliosis to have neurological symptomsScoliosis associated with kyphosis are more likely to have neurological complicationsPresence may indicate spinal cord anomaly (Headaches, neck pain, hand numbness could happen in Chiari malformation)
26 Spastic gait due to spinal cord compression in a congenital kyphoscoliosis.
Cardiopulmonary Problems27 Curves more than 80 to 100.
Ask for breathing difficultyShortness of breath on running with friendsRecurrent respiratory infections / hospitalizations
History
•Birth History - Consanguinity ? - Issues in pregnancy ? - Health of mother? Diabe6c? Antenatal care
appropriate? - Previous pregnancies ending in
miscarriages? - Issues during perinatal and postnatal
period - Term delivery? C-sec6on or vaginal - ICU / ven6latory care
28
History
•Developmental History - Motor milestones - Learning disabili6es - Grade in School? Keeping up with
peers
29
History
•Skeletal Maturity - Menarche (record in yr+mo)
- Premenarchal - Ask about Mother’s or Elder sister’s menarche
- Shoe size? Changes in size of clothes?
- Shaving regularly?
30 Menarche / Axillary hair appearance= approximately after 2 years growth will stop.
Skeletal growth in boys is completed when they are (or should be) shaving every day.
Linear growth is near completion when there has been <1 cm of change in standing height over a six-month period
History
• Family History - Parents and their families (AIS, NM, NF) - Siblings (7% - AIS) - Examine family if in room - Adam’s test
31 AIS tends to run in families; the risk of scoliosis in the sibling of an affected patient is approximately 7 percent but may be increased if one of the parents was also affected
History
•Past medical or surgical history - Hearing / visual problems - Clej lip/ palate - Tracheo-esophageal fistula, Anorectal
•CURVES • Loca6on (apex) • Side (Right or lej) - convexity • Largest curve (Major curve)
C-shaped curvesS-shaped curves
43
• HOW SCOLIOSIS IS AFFECTING SYMMETRY?
- Shoulder level - Rib prominence - Asymmetric flank crease - Arm to trunk gap - Pelvic level
Back44
• BALANCE •Global •Trunk
Back45 Global balance means a plumb line dropped from he C7 falls in the natal cleft.
Imbalance means head is not centered over the pelvis.
Back
• BALANCE •Global •Trunk
46 Midpoint at the level of the maximum width of the thorax and drop a plumb line from here. Measure deviation from the natal cleft. This is more common in single curve. C-Shaped. Less common in double curve patterns (S-shaped curves)
1) To assess the ROTATIONAL COMPONENT of scoliosis → in forward position the anterior column shortens and a scoliotic spine rotates and buckles out making the prominence larger. (Screening tool (can pick up early deformities)
2) To assess the SAGITTAL CONTOUR as well. Difference between familial round back (Smooth) and Scheuermann kyphosis (more angular)
NOT to differentiate functional from structural scoliosis
Side ViewRear View
RotationalDeformity
SagittalDeformity
49 You have to take a look at the patient from two views. The side view shows the sagittal contour and the rear view shows the rotational deformity
As a general guideline, an ATR (Axial trunk rotation) of 7° corresponds to a Cobb angle of 20°. However, not all patients with radiographic scoliosis have rotation of the trunk, and not all patients with trunk rotation have radiographic scoliosis. In overweight children, the traditional correspondence of a 7° ATR to a 20° Cobb angle may not be accurate.
Adam’s Forward BendingLumbar Prominence
51 Example of lumbar prominence in a patient with lumbar scoliosis.
Adam’s Forward BendingRib Prominence
Sharp Smooth
52 Note the same of the rip prominence. Sharp or smooth.
Another way to measure the severity of the rib prominence is to drop a plumb line over the prominence and make the thread horizontal and measure the distance of the horizontal thread form the left side of the back.
Adam’s Forward Bending53 There are two ways to measure the ATR.
Angle measurement Distance measurement - KEEP the scoliometer horizontal and then measure the distance from the corresponding mark (similar to the one that is touching on the prominence)
- Head 6lt - Neck line - Chest asymmetry - Rib impingement - Pelvis ASIS - Secondary sexual characters - Skin
59 Bending on the convexity of the curve over the examiner’s hand on the ribs that connect to the apex.
Flexibility Trac6on
60 Small kids can be lifted up to see flexibility.
Flexibility Push Prone Test
61
Flexibility Prone Hyperextension test
62 Can also examine for tender points in this position. Best position to test correctibility of kyphosis.
Head to Toe63
Head to Toe64
Physical ExaminaBon Head to Toe Exam
65 Marfan’s - Arachnodactyly, high arch palate, Long arm span, ectopic lens
Head to Toe66 Dimple or Hairy patch - sign of congenital neuraxis abnormality
M
Head to Toe67 Cafe U lait spots in NF1
Plexiform neurofibroma in NF1
Head to Toe68 Foot size asymmetry, Cavus foot, claw or hammer toes.
Head to Toe69 Limp length discrepancy
Many people have leg length discrepancy of <1 cm (0.4 inches); the magnitude of difference that results in compensatory scoliosis varies from person to person but typically is >2.5 cm (1 inch). Children with clinically significant leg-length discrepancy should be evaluated.
Hyper flexibility Beighton Score
70 Ehlers Danlos syndrome and other connective tissue disorders.
- 14+6y old girl who is 18 months postmenarchal - with right sided thoracic scoliosis, - probably adolescent onset idiopathic, - with truncal decompensa6on but without head
decompensa6on, - par6ally flexible - normal neurology
73 Ideal should be a AP view (clearer than PA) for the first assessment and then PA for the rest (PA view has less radiation to the breasts)Shoulders, rib cage, pelvis (with triradiates seen at least for the first evaluation)Use gonadal screen for subsequent Xrays. In this Xrays the arms should be on the side. to assess radiographic shoulder balance
74
Flexibility films only for Surgical Planning
75
im
A
60 degrees
Vaughan JJ, Winter RB, Lonstein JE. Comparison of the use of supine bending and traction radiographs in the selection of the fusion area in adolescent idiopathic scoliosis. Spine 1996;21:2469–2473.
76 Larger curves require traction films to demonstrate true flexibility of the curve.
53° 30° 10°
Trac6on Bending
77 This case illustrates the effectiveness of bending films in less than 60 degree curves. The curve corrects less in traction.
78 Take these Xrays Supine. On 14x17 inch cassette
79 Traction film best when >60 deg curve, or in neuromusculars when active bending is difficult.
Terminology• Apical Vertebra
• End Vertebra
• Neutral Vertebra
• CSVL
• Stable Vertebra
T9
L2
80 Apical - is most rotated and most laterally deviated.End - vertebra which is most tilted into the concavity of the curveNeutral - pedicles are equidistant and symmetrically seen. Stable - most closely bisected by the CSVL
Good example of how the head is balanced over pelvis but the thorax is not.
Terminology• Cobb angle
• Use same levels
(bending)T9
L2
57°
30°
29°
22°
-19°
81
M
Terminology• Shoulder level
• Right higher
• Lej higher
T9
L2
82
Terminology• Pelvis obliquity
T9
L2
83
Terminology• Thoracic Kyphosis
• Lumbar Lordosis
• Thoracolumbar (T10-L2)
• SVA (Sagiqal Ver6cal Axis)
• From C7
• Within 5 cm of posterior superior corner of S1
T9
L2
84
Terminology• Structural Curve
• Non-structural Curve
85 Structural- Lateral curvature that lacks normal flexibility. Failure to correct fully on side bending. Non-structural - corrects fully or over corrects.
86 25 degree is a very arbitrary number - useful for planning surgery. But is not the true definition of a structural curve.
Terminology• Structural Curve
• Non-structural Curve
• Major Curve
• Minor Curve
87 Largest Structural curve is a major curve
Terminology• Structural Curve
• Non-structural Curve
• Major Curve
• Minor Curve
• Primary Curve
• Secondary Curve
88 Primary Curve - The curve to appear first is primary, if identifiable.
Terminology• Structural Curve
• Non-structural Curve
• Major Curve
• Minor Curve
• Primary Curve
• Secondary Curve
• Full Curve
• Frac6onal Curve
89 Full curve - The only horizontal vertebra is the apical vertebraFractional curve - Incomplete curve. The horizontal vertebra is the cephalad or the caudal one.
Skeletal maturity
Closed Triradiate
Risser 3/4
90 Risser 1 is equivalent to Menarche / appearance of axillary hair. (2 years growth remaining)Risser 4 - only 1 cm growth remaining.
MRI
• Non-idiopathic Scoliosis
• Presumed idiopathic Scoliosis
• Abnormal neuro-exam
• Pain
• Rapid ↑ magnitude
• Thoracic hyperkyphosis (30-40°)
• Abnormal curve paqerns (lej thoracic, double thoracic, triple, long right thoracic with end v caudal to T12)
