Scoliosis Mr. Christopher I. Adams

National Services Division - “Spinal Surgery” Year Budget £ Procedures No. 2005 / 06 2,746,093 109 2006 / 07 2,912,821 145 2007 / 08 3,124,282 201 2008 / 09 ? 213 2009 / 10 239 2010 / 11 4,910,000 (78%) 259 (137%) www.nsd.scot.nhs.uk/publications/

OCAP & FRCS (Tr and Orth) / ST3-6 Applied Clinical Knowledge Syllabus The Spine (Sec. 8-13) “A basic knowledge of the surgery of spinal deformity and tumours of the spine”. Competence level 3 = “Knows generally”. Paediatric Orthopaedic Surgery (Sec. 8-14) “Knowledge of the neurological processes involved in the production of deformity e.g. spina bifida, cerebral palsy and muscular dystrophy”. Competence level 3 = “Knows generally”. Clinical Procedures Syllabus Thoracic Spine – Scoliosis correction – posterior (Sec. 8-24) Competence level 1 = “Has observed or knows of”. ST7-8, Competence level 3s = “Can manage whole but may need assistance”. Interrupt at any time for questions…if you are thinking it, so are others.

Today’s Plan Pathology Measuring Scoliosis Treating Scoliosis Differences when not idiopathic Congenital Handout All references Crib sheet

Classification - Pathology Idiopathic (36%) Neuromuscular (21%) Duchenne = 15 patients Congenital (10%) West of Scotland clinics = 414pts 2yr 10m, 26 Nov 2006 to 15 Sept 2009

Clinical Assessment History Examination deformity pain general health development & maturity family history Examination general (diagnosis) specific (deformity)

General Examination General appearances Skin Joint laxity palate, ears, neck Skin hair patches, skin dimples scars café au lait patches Joint laxity Spinal dysraphism leg length, foot size inequality foot deformities asymmetric abdominal reflexes

Examination of the Back

Quantifying Spinal Deformity C7 T3 T5 T7 T9 T11 L1 L3 L4 Sacrum

Surface and Spine Measures Bunnell WP. JBJS [Am] 1984; 66-A: 1381-7.

Clinical and Surface Topography

Cobb Angle θ Outline for the Study of Scoliosis. Cobb, John R. (New York, New York, U.S.A.) American Academy Instructional Course Lectures 1948;Vol. 5: pg 266.

Classification - Type of curve - OLD

Classification - Type of curve Lenke

Spinal Height Gain (cm/yr) Spinal Growth Spinal Growth Velocity Risser Sign Spinal Height Gain (cm/yr) Age

GROWTH VELOCITY OF THE SPINE 3 months later

Scoliosis Progression Younger patients + large curves = great risk of progression Increased growth  greater deformity Larger curves (> 50º)  spontaneous buckling Progression in adulthood 98o 130 cm

The Spinal - Rib Cage Connection Nash and Moe. A Study of Vertebral Rotation. JBJS [Am] 1969; 51-A: 223-9.

Objectives of Surgery Cosmesis Prevention of curve progression Correction of curve Reduce the cardio-pulmonary consequences of scoliosis Avoid neurological complications

Posterior Spinal Surgery Case ♀ - AIS 66%

Pedicle Screw Constructs - Idiopathic Scoliosis 15.11.2006 15yrs 1mth 08.03.2007 15yrs 5mth 58 o 23 o 45 o 23 o

Anterior Release & Costoplasty

Intra-operative Monitoring - European Literature “Reviewing the literature on intraoperative monitoring makes it clear that application of a single method such as SEPs is not sufficient and that accounting for ascending and descending pathways of the spinal cord and nerve roots requires a multimodal approach.” Current opinion and recommendations on multimodal IOM during spine surgeries. With Spinal Osteotomy. Sutter M, Delitis V, et al. (Multicentre) Eur Spine J 2007;16 (Supp2): pg S232-7. 23

Intra-operative Monitoring - Literature Paper Year (pub) Deformity IOM +ve Neurology Bridwell n= 500pt 1987-97 (1998) Scoliosis ? 0.01% to 0.05% SRS n=670pt 2001-4 Kyphosis 0.4% Vitale n=151pt 1999-05 (2010) 8% 1.3% Lenke n=42pt 2000-06 (2008) 21% 2.4% (recovered) U.K. N=~1400 24

Syrinx Retrospective 1992 – 2005 n = 13 11 yrs 1 mth (3.6–16.4 years) The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland) Spine 2007;32 (21): pg 2327-33.

Syrinx All fusion surgery No neurological deterioration 4vs= 4th ventriculo-arachnoid shunt The Outcomes of Scoliosis Surgery in Patients with Syringomyelia. Bradley LJ, Ratahi ED, Crawford HA & Barnes MJ (Auckland, Newzeland) Spine 2007;32 (21): pg 2327-33.

Syrinx – Case ♀ 13y10m Hx fall off trampoline 2yrs Left mid thoracic back pain, no radiation. Neurology Symm. Absent abdominal reflexes

Syrinx – Case ♀

Posterior decompression Syrinx – Case ♀ Posterior decompression by Miss Lynn Myles 16/09/2009

“Superior Mesenteric Artery Syndrome in Paediatric Orthopaedic Patients” 1842 Rokitansky N = 14 pts 1979 to 1987 Presentation Nausea Intemittent and large bile-stained vomiting Between normal appetite Bowel sounds present “SMA syndrome in paediatric ortho pts” Hutchinson DT and Bassett GS. from Ann Arbor, Michigan, USA Clin Orth and Rel Research 1990 ;250:pg250-7.

Changing Practice - Spina Bifida 29.04.2008 2yrs 8mth 196 05.02.2008 17yr 2m 164 Only 10% no spinal deformity JBJS Br 1980; 62-B: p54-8 6 to 12 degrees per yr

Spina Bifida - Case ♀ 8y8m Pre-menarche Braced since 18mths Now tripod sitting Motor level L1 VP shunt Vesicostomy PEG Painless right hip dislocation Picture no97

Spina Bifida - Case ♀ 27.07.2007 no97

Spina Bifida - Case ♀ 26.07.2007 31.07.2007 8yrs 9mth 8yrs 9mth no97

Spina Bifida - Case ♀ Outcome 12.06.2007 8yrs 8m 11.12.2007 9yrs 2m Brace NO brace no97

Surgical Objectives Preserve Neurology Spinal and pelvic alignment bowel and bladder sensation use of legs Spinal and pelvic alignment Level shoulders & pelvis CoG over sacrum Unaided sitting with stability Relationship to the hip Avoid other complications

Congenital

Congenital “Congenital deformities of the spine” McMaster MJ J R Coll Surg Edinb 2002;47:p475-80

Congenital - Case ♂

Discussion / Comments / Questions …