SPINAL DEFORMITY

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SPINAL DEFORMITY

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1. SPINAL DEFORMITY Mr A Sivaraman FRCS(Eng) FRCS(Ed) FRCS(Orth) Consultant Orthopaedic Spinal Surgeon The Royal London & St Bartholomew's Hospital London

2. SPINAL DEFORMITY SAGITTAL- KYPHOSIS LORDOSIS SPONDYLOLISTHESIS CORONAL- SCOLIOSIS

3. SCOLIOSIS

4. AETIOLOGY CONGENITAL IDIOPATHIC NEUROMUSCULAR POSTTRAUMATIC INFECTIVE TUMOUR INFLAMMATORY DEGENERATIVE

9. INVESTIGATION RADIOGRAPHS- AP,LAT,BENDING VIEWS MRI CT SCAN- IN SEVERE CURVES

10. RADIOLOGICAL PARAMETERS END VERTEBRA APICAL VERTEBRA NEUTRAL AND STABLE VERTEBRA CURVE LOCATION CURVE MAGNITUDE- COBB ANGLE RISSER SIGN ROTATION

11. CONGENITAL SCOLIOSIS McMaster CLASSIFICATION FAILURE OF FORMATION FAILURE OF SEGMENTATION

12. Congenital Spinal Deformities - Defects of Formation

13. Congenital Spinal Deformities - Defects of Segmentation

14. CONGENITAL SCLIOSIS ASSOCIATIONS 60% OTHER ANOMALIES 25% CERVICAL ANOMALIES 37% GU ANOMALIES 38% INTRASPINAL ANOMALIES TETHERED CORD DIASTAMATOMYELIA SYRINGOMYELIA CLUBFOOT,CARDIAC(VACTERLS)

15. RISK OF PROGRESSION UNILATERAL UNSEGMENTED BAR WITH CONTRALATERAL SEGMENTED HEMIVERTEBRA UNILATERAL UNSEGMENTED BAR MULTIPLE FULLY SEGMENTED HEMI-VERTEBRA

16. TREATMENT PRINCIPLES INSTRUMENTED/UNINSTRUMENTED FUSION COMBINED ANTERIOR AND POSTERIOR PROCEDURES HEMIVERTEBRA EXCISION CONVEX GROWTH ARREST

17. SCOLIOSIS CONGENITAL INFANTILE JUVENILE ADOLOSCENT ADULT

18. SCOLIOSIS EARLY ONSET- < 7YEARS LATE ONSET- > 7 YEARS

19. AIS - ASSOCIATIONS FEMALES ADOLESCENSE 3% PREVALANCE 0.3% REQUIRE TREATMENT CONVEX TO RIGHT NO PAIN FAMILY HISTORY- 27%, 11%, 3% HORMONAL FACTORS- MELATONIN, CALMODULIN

20. ASSESSMENT Hx- FAMILY,PERINATAL DEVELOPMENT SYMMETRY ADAMS FORWARD BEND TEST NEUROLOGIC ASSESSMENT SCOLIOSIS LONG FILMS- STANDING AND BENDING FILMS

21. RISK OF PROGRESSION YOUNG AGE AT DIAGNOSIS DOUBLE CURVES FEMALE LEFT SIDED CURVES CURVE MAGNITUDE

22. TREATMENT OPTIONS OBSERVE- <25* ORTHOSIS- 25*- 40* APEX ABOVE T8- CTLSO APEX BELOW T8- TLSO ( Nachemson et al, JBJS 1995) OPERATE- >40*

23. NATURAL HISTORY CURVES < 30* - NO PROGRESSION ½-1* PER YEAR IN ADULT LIFE (WEINSTEIN ET AL, JBJS 1983) ASSOCIATION WITH BACK PROBLEMS ?? PULMONARY AND CARDIAC EFFECTS > 90*

24. Team approach Surgeons Anaesthetists Nurses Physiotherapists Orthotists

25. Goal of Surgery To produce safe maximal correction with anterior / posterior instrumentation / reconstruction To restore good frontal and sagittal balance

26. Basic concepts in the surgical management of the severe / rigid deformity of the spine Posterior Soft tissue Osteotomies Anterior Discectomies Vertebrectomies

27. SCOLIOSIS SURGERY LANGE RODS 1910 RUSSELL HIBBS FUSION 1917 PAUL HARRINGTON RODS 1962 ALAN DWYER ANTERIOR CABLES 1969 LUQUE SEGMENTAL WIRING 1973 ZIELKE ANTERIOR SYSTEM 1978 COTREL DUBOUSSET SEGMENTAL PEDICULAR SYSTEM 1984 ISOLA GROWING RODS 1992

28. SCOLIOSIS SURGERY ANTERIOR DWYER ZIELKE NEWER SYSTEMS POSTERIOR HARRINGTON LUQUE COTREL DUBOSSET

29. SURGICAL TREATMENT ANTERIOR VS POSTERIOR COMBINED PROCEDURES THOROCOPLASTY NEUROLOGCAL MONITORING- SEPS,MEPS

30. POSTERIOR SURGERY TRADITIONAL NO VIOLATION OF BODY CAVITIES NO REDUCTION IN PULMONARY FUNCTION( UPTO 15% REDUCTION) NEUROMUSCULAR CURVES WITH POOR PFT(<30%) DOUBLE MAJOR CURVE WITH SHOULDER ASYMMETRY

31. POSTERIOR SURGERY HYPERKYPHOTIC DEFORMITIES PREVIOUS ANTERIOR SURGERY OSTEOPOROSIS PATIENT SIZE CURVE ABOVE T4

32. ANTERIOR SURGERY FEWER SEGMENTS TO FUSE (Richards et al ,Spine 1989) SINGLE THORACIC CURVE YOUNGER PATIENTS WITH GOOD PULMONARY RESERVE THORACIC KYPHOSIS LESS THAN 40*

33. ANTERIOR SURGERY THOROCOTOMY THOROCOABDOMINAL RETROPERITONEAL

34. NEUROMUSCULAR SCOLIOSIS NEUROPATHIC UMN CP HSMN SYINGOMYELIA LMN SMA POLIO DYSAUTONOMIA (Riley Day syndrome) MYOPATHIC ARTHROGYPOSIS MUSCULAR DYSTROPHIES MYOTONIA

35. ASSESSMENT FUNCTIONAL STATUS SITTING BALANCE RESPIRATORY FUNCTION NUTRITIONAL STATUS SEIZURES OSTEOPENIA

36. PRINCIPLES OF TREATMENT GENERAL- CARDIAC, RESPIRATORY, NUTRITIONAL BRACING USUALLY INEFFECTIVE LONG FUSIONS USUALLY TO PELVIS

37. DEGENERATIVE SCOLIOSIS BACK PAIN SYMPTOMS OF SPINAL STENOIS ASYMMETRIC FACETAL WEAR VERY DIFFICULT PROBLEM

38. SPONDYLOLISTHESIS

39. SPONDYLOLISTHESIS DYSPLASTIC ISTHMIC DEGENERAIVE TRAUMATIC PATHOLOGIC POST SURGICAL

40. ASSESSMENT LOW BACK PAIN HAMSTRING TIGHTNESS L5 DYSFUNCTION XRAY- AP,LATERAL, OBLIQUE DEGREE OF SLIP SLIP ANGLE

41. MANAGEMENT PRINCIPLES REDUCTION Vs IN SITU FUSION POSTERIOR VS ANTERIOR COMBINED

42. DEGENERATIVE SPONDYLOLISTHESIS COMMON AT L4 L5 SPINAL STENOSIS DECOMPRESION AND FUSION

43. KYPHOSIS CONGENITAL SCHEURMANN”S ANKYLOSING SPONDYLITIS POST TRAUMATIC POST INFECTIVE OSTEOPOROTIC CAMPTOCOMIA

44. BIOMECHANICS ANTERIOR COLOUMN-RESIST COMRESSIVE FORCE POSTERIOR COLOUMN- RESIST TENSILE FORCE IMBALANCE- KYPHOSIS

45. SCHEURMANNS KYPHOSIS – SORENSON’S CRITERIA ANTERIOR WEDGING OF 5* IN THREE CONSECUTIVE LEVELS END PLATE IRREGULARITIES KYPHOSIS > 45*

46. ANKYLOSISNG SPONDYLITIS SERONEGATIVE INFLAMMATORY ARTHROPATHY 0.2- 0.3% PREVALANCE MALES DECREASED CHEST EXPANSION KYPHOSIS

47. SURGICAL OPTIONS SMITH-PETERSON OSTEOTOMY PEDICLE SUBTRACTION OSTEOTOMY COMBINED PROCEDURES FUSE LONG ALWAYS RESTORE SAGITTAL BALANCE

48. CERVICAL BASIAR IMPRESSION ATLANTO AXIAL ROTARY SUBLUXATION- TORTICOLLIS ARNOLD CHIARI MALFORMATION SYRINGOMYELIA KLIPPEL-FEIL ANOMALY

49. SPINAL DYSRAHISM FIBROCATILAGENOUS OR BONY SEPTUM CUTANEOUS LESIONS FOOT DEFORMITIES NEUROLOGIC DEFICITS SCOLIOSIS SPINA BIFIDA WIDENED INTERPEDICULAR DISTANCE

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