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January 21, 2011 Meghan N Imrie, MD Pediatric Orthopaedic Surgery Lucile Packard Childrens Hospital
Disclosures
none
Introduction
On the Horizon
Definition
Scoliosis
Derived from Greek for crooked Coronal plane deformity > 10o
< 10o = spinal asymmetry Measured by the Cobb method
Definition - continued
idiopathic
What must be ruled out?
Neurofibromatosis Marfan syndrome Ehlers Danlos syndrome Intraspinal abnormalities
Tumors Tethered cord Syrinx
Varies by age:
Infantile - birth to age 2 years Juvenile - from about 2 to 8 or 9 years Adolescent - greater than 9 or 10 years, but not an adult
Overview
On the Horizon
Etiology
Family history
27% prevalence of scoliotic curves >15 degrees in daughters of scoliotic mothers2
Curve type
Majority right thoracic (about 98%)
Left thoracic is red flag for possible intraspinal abnormality
1. 2. Bunnell WP Spine 1986;11:773-6. Harrington PR Clin Orthop 1977;126:17-25.
Etiology
Overview
On the Horizon
Prevalence
Natural History
Progression
Before skeletal maturity After skeletal maturity
Natural History
Natural History
Risser sign
Radiographic measurement based on ossification of iliac apophysis
Natural History
Natural History
Natural History
Natural History
Natural History
Natural History
Natural History
In summary:
Trying to prevent curves from reaching at skeletal maturity:
>50 degree thoracic >40 or 45 degree lumbar
Because these curves continue to progress in adulthood Adults with untreated, more mild scoliosis do well in adulthood (at least in Iowa)
Overview
On the Horizon
Screening
Somewhat controversial
AAOS, SRS, POSNA and AAP currently recommend1:
Females screened twice at ages 10 and 12 Males screened once, at age 13 or 14
British Orthopaedic Association and British Scoliosis Society advise against screening United States Preventive Services Task Force (USPSTF) in 2004 recommended against screening
AAOS, SRS, POSNA, AAP responded with 2008 information statement1
1. Richards BS and Vitale MG JBJS Am 2008;90:195-8.
Screening - controversy
In summary:
Screening is fairly reliable to detect curves (though not terribly accurate) Early detection could result in improved health outcomes (by potentially avoiding surgery) Brace therapy is likely effective in altering natural history for many patients (but not all)
Evaluation
History
Reason for presentation (in patient or parents own words Pain
Red flag warnings: positive finger test, night pain, nonactivity related pain
Age Family history Pubertal status Rate of progression Any neurologic complaints
Radicular symptoms Bowl/bladder incontinence
Evaluation
Painful left thoracic curve or abnormal neuro exam more likely to have neuro-axis problem
Evaluation - radiographs
Evaluation
Evaluation
Classification systems
King-Moe Lenke
Evaluation
Classification systems
King-Moe Lenke
Overview
On the Horizon
Treatment
Surgery
Treatment
11-25o 25-45o >40-50o
Skeletal maturity?*
Skeletal maturity?
yes
no
yes
F/u as needed
Natural History
Treatment - bracing
Types
Full-time bracing
Boston Milwaukee (if apex higher than T7)
Others
Spine-Cor
Treatment - bracing
TLSO (Boston-type)
Worn as much as possible
Can take off for sports, sleepovers etc
Treatment - bracing
Milwaukee brace
For refractory curves Apex >T7 Not really tolerated in our patient population
Treatment - bracing
1. 2.
Treatment - bracing
SpineCor
Well advertised Soft straps, so more easily worn under clothers/during physical activity Originators report only 40% progressed, only 23% needed surgery1
Other authors have found no better results with SpineCor2
1. 2.
Christine C et al. Stud Health Technol Inform 2008;135:341-55. Wong MS et al Spine 2008;33:1360-5.
Treatment - bracing
Brace efficacy Data all over the place, both for and against Meta-analysis by Rowe et al1
1910 patients in 22 studies on non-operative treatments
Weighted mean proportion of success 0.93 for bracing 0.49 for observation 0.39 for electrical stimulation
3.
Treatment - bracing
Best for:
Girls1
Boys only 38% compliant with brace wear 30 degree curve 50% chance of surgery BMI >85th %ile --> 2.5x risk of failure, double surgical rate
Lower BMI2
2.
Treatment - bracing
Summary:
Probably alters natural history in some but not all
Especially if patient young, thin, and compliant Curve can definitely still progress
Treatment - surgery
Goals of surgery:
Achieve solid fusion SAFELY! (improve cosmesis, body image)
Treatment - surgery
Treatment - surgery
No long-term, prospective controlled studies to support hypothesis that surgery for AIS is superior to natural history
Reliably prevents progression Achieves permanent correction Improves appearance
Treatment - surgery
1964, Moe
Harrington rods, Risser cast Ave correction 55% --> 41%
1964, Moe
Harrington rods, Risser cast Ave correction 55% --> 41%
1992, Lenke
CDI - Cotrel Dubousset instrumentation Ave correction 48%
2005, Suk
Introduction of pedicle screw Ave correction 62%
Approach:
Posterior vs Anterior
Open vs Thoracoscopic
Combined approach
For very big, stiff curves Younger patients
To prevent crankshaft
Approach
Posterior exposure Careful at most cephalad and caudal ends to avoid unnecessary exposure +/- Use of C-arm
Screw placement
Free-hand With C-arm With O-arm Definitely dealers choice
Correction
In 3 planes
Coronal (straight rods) Axial (derotation) Sagital (rod contour)
Screw types
Monoaxial Uniplanar Polyaxial
Closure!
+/- drain +/- brace
Overview
On the Horizon
On the Horizon
Based on 53 genetic markers Log scale from 0 to 200 Very high and very low scores helpful, middle score unclear Not widely used or accepted Expensive May be more helpful in research
Ie are curves with high scores those that progress despite a brace?
On the Horizon
Fusionless techniques:
Compressing anterior overgrowth
Vertebral stapling Spinal tethering
Newton et al Encouraging results in animal model Human trials just starting
Summary
AIS
3-dimensional deformity Defined as 10 degrees of curve on PA xray Exact cause unknown; watch for red flags Screening controversial but still recommended by most
Girls at 10 and 12 years (younger better) Boys at 13 or 14 years
> 7 degrees on Adams forward bend, consider xray vs referral to orthopaedist Treatment
Based on age and size of curve Includes observation, bracing, and surgery
Thank you