Exam 9 Nmsk63 - Spine Deformities

Front 1

... – defect in the pars interarticularis of the vertebra

Common after athletic activities requiring ... (gymnastics and lineman)

back pain

Back 1

Spondylolysis
hyperextension

Front 2

Incidence of spondylolysis:

-Prevalence in children at 6 yo is ...-...%
-At 18 increased to ...%
-Risk factors include family hx, spina bifida occulta, scoliosis, Alaskan Eskimo heritage
-Most common at ...
*Area where you have highest amount of stress

Back 2

4-5
6
L5-S1

Front 3

Presentation of spondylolysis:

-dull, ... back ache
-worsening over a month
-not associated with ... pain
-exacerbated with rotation/...
-rare neurologic symptoms (not a nerve impingment)
-increase in training (frequency/intensity)

Back 3

unilateral
night
hyperextension

Front 4

Radiographic imaging of spondylolysis:

Most can be diagnosed with ...
Standing oblique x-rays
Standing PA/lateral TLS
Spot lateral at L-S junction
Bone scan
Thin cut CT scan, ... (gold standard-thin cut CT)
MRI

Back 4

plain radiographs
SPECT

Front 5

Treatment of spondylolysis:

Stress reaction/fracture
-Goal is ... of injury
-Prevention of progression
-Immobilize for 6-12 weeks with ...
-Immobilization stopped with evidence of healing
-Return to play when painless spinal mobility without ... spasm
-No activities until 100% ... free

Back 5

healing
TLSO (thoracic lumbosacral orthosis)
hamstring
pain

Front 6

Surgical treatment of spondylolysis:

Indications/Options
-... pain
-... months non-operative treatment
-Failed bracing
-Gold standard is fusion ...-...
-Repair of defect is recommended for ...-...
-Wiring and screw techniques

Back 6

Persistent
6
L5-S1
L1-L4

Front 7

... - Forward slippage of proximal vertebrae on distal vertebrae

Back 7

Spondylolisthesis

Front 8

Meyerding grades the spondylolisthesis as the percent ... displacement of the superior vertebra on the lower body.

Meyerding System
-Grade I – 0%-...%
-Grade II – 26%-50%
-Grade III – 51-75%
-Grade IV – 76%-100%
-Grade V - >100%

... – all the way off. (will present with bent knees, tight hamstrings)

Back 8

anterior
Spondyloptosis

Front 9

Symptomatic:

Less than ...% slip
-Conservative care
-Consider anti-lordotic brace

Slip from ...-...%
-Activity restriction, bracing until pain free
-Flexion exercises, hamstring stretching

Slip greater than ...%
-Surgical stabilization

Back 9

25
25-50
50

Front 10

Surgical indications:

Pain greater than ...-... months
Unrelieved with ... and immobilization
... of spondylolisthesis
Slip greater than ...%
... deficits

Back 10

6-12
rest
Progression
50
Neurologic

Front 11

Postural Round Back

Thoracic Kyphosis without ... changes

Forward bend increases kyphosis but no sharp ... as in Scheuermann’s disease

TX- hyperextension exercise program-strengthen those muscles in the back-make them aware of not slouching

Back 11

vertebral body
angulation

Front 12

... - Avascular necrosis of vertebral endplate

-Disease of adolescents
-At least 5 deg anterior wedging of a least 3 adjacent thoracic vertebrae
-8% of population affected
-Equal gender distribution
-Commonly diagnosed in early adolescence
-No ... plane (scoliosis) deformity
-Significant ... plane deformity
-Thoracic kyphosis
*Rigid on attempts at correction
-... hyperlordosis

Back 12

Scheuermann’s Kyphosis
coronal
sagittal
Lumbar

Front 13

Etiology of Scheuermann’s Kyphosis is ...

Genetic
Growth hormone
Mechanical factors
Altered ratio of collagen to proteoglycans
Juvenile osteoporosis
Defective cartilage endplates

Back 13

uncertain

Front 14

Scheuermann’s Kyphosis presentation:

Adolescents ...-... years old – during growth spurt (opportunity to act the quickest)

Increasing spinal curvature

... deformity
-Pain is common if initial presentation in adults

Associated ... and scoliosis

Rare ... complaints

Back 14

12-16
Painless
spondylolisthesis
neurologic

Front 15

Conservative treatment for SK:

Physical therapy
-Hamstring strengthening
-Trunk extensor strengthening

... for pain

Bracing
-Poor compliance
-... brace for 23 hours a day for 1-2 years
-Limited outcomes studies

Back 15

NSAID’s
Milwaukee

Front 16

Surgical indications for SK:

Intractable ...
-More common in adults

Curves >... degrees

Cardiopulmonary or neurologic compromise

Back 16

pain
75

Front 17

Key points for SK:

Radiographically defined as presence of ... or more adjacent vertebrae with at least ... degrees of anterior wedging

Adolescents generally present with ... progressive deformity and cosmetic complaints, while adults present with ...

Back 17

3
5
painless
pain

Front 18

...:

Lateral Deviation and Rotation of a series of vertebrae from the midline anatomic position

Lateral Curvature of the spine exceeding 10°

Back 18

Scoliosis

Front 19

What is the most common type and presentation of scoliosis?

Back 19

Adolescent idiopathic scoliosis
Convex right thoracic (rib hump on the right)

Front 20

Etiology of scoliosis:

-Majority have ... etiology
-Scoliosis is a ..., NOT a diagnosis
-Must rule out neurological and structural causes
-... scoliosis: Fixed deformity that does not correct on lateral bending
-severe pain, convex left thoracic curve and abnormal neurologic exam point to ... cause for spinal deformity

Back 20

unknown
physical sign
Structural
secondary

Front 21

...% of Scoliotic curves are Idiopathic (occur without a known cause)

30% of patients have family members with significant scoliosis
*No gene has been located (probable multigene dominant condition with variable phenotypic expression)

Back 21

80

Front 22

Infantile idiopathic scoliosis:

-occurs birth to ... yrs old
-... curve most common
-boys ... girls
-The earlier it is diagnosed and the more aggressive the deformity, the more likely that tx will be necessary
-90% spontaneous resolution
-girls with ... curve poor prognosis

Back 22

3
left thoracic
>
convex right

Front 23

Infantile idiopathic scoliosis:

Rib vert angle difference less than ... deg has low likely hood of progression

Back 23

20

Front 24

Infantile Idiopathic Scoliosis:

...% progress, ...% resolve, ...% do not change

If cobb curve < ... degrees, observation
if between ...-... degrees, brace
if >... degrees, neuro/MRI work up, instrumentation combined with anterior and posterior fusion

Back 24

50, 10, 40
25
25-35
35

Front 25

Juvenile Idiopathic scoliosis:

Occurs ... to ... Years of Age
Female to Male Ratio ...
70% require treatment
50% will eventually need corrective surgery
50% need bracing

Back 25

3 to 10
4:1

Front 26

Adolescent idiopathic scoliosis

-10 years of Age - Skeletal ... (Closure of epiphyses)
-Female to Male Ratio ... (require treatment)
-Convex ... (most common)
*If you see convex ..., start thinking of other things

Back 26

Maturity
9 : 1
Right Thoracic
left

Front 27

Clinical screening:

... Test: Definitive Clinical Test
* Structural Scoliosis: The vertebrae rotates to the convex side of the lateral curvature, spinous process rotates toward the concavity.

... bending: To determine if the curve goes away when the patient bends toward the side of the rib hump
* Structural Scoliosis is a fixed deformity that ... correct on lateral bending.

...: Used during Forward Bending to assess angular prominence
* Screen if trunk rotation is >7°
* Look for the rib hump on the convex side of curve

Back 27

Adams Forward Bending
Lateral
does not
Inclinometer

Front 28

The majority of Scoliosis is detected between the age of 10-15yrs

Curvature deformities are 3-5 times more likely to progress and produce subjective symptoms in ....

Significant growth occurs 6 -12 months before ...
-Bracing works better if they have not had their ... yet

Curves of 11° or more are seen in 2% of early adolescents
-0.2% of these curves will worsen to need tx

Back 28

girls
menarche
period

Front 29

Adolescents with scoliosis are usually ...

Back 29

asymptomatic

Front 30

Non Treatment complications:

Degenerative Spinal Arthritis: Loss of ... height, osteophytes, intersegmental instability

Cardio Pulmonary Complications:
-seen in progressive scales beginning <5 years of age
- >75 degrees compromises ... functions
- Thoracic curve >50 degrees compromises ... functions
- Cor Pulmonale thoracic curves > 90°

Back 30

disk
cardiovascular
respiratory

Front 31

Indications of likely progression:

~ Curves > ... degrees are more likely to progress if Risser 1-2, 68%
~ Curvature Pattern : Double primary, lumbar primary curvature
~ Gender: ... > Male
~ Age: ... Maturity
~ Onset of Menarch (early onset): increased risk for growing girls with established curve of >... degrees or more

Back 31

20
Female
Skeletal
11

Front 32

MRI:

Identifies ... abnormalities (Arnold-Chiari malformation and syringomyleia)

Perform MRI on Infantile Scoliosis with Cobb angle > ... deg

Neural Axis abnormality in 21%-50%

Adolescent idiopathic thoracic convex L

Back 32

spinal cord
20

Front 33

skeletal maturation:

Iliac Crest Epiphyses (... Sign) :
*Begins laterally at ASIS and progresses medially to PSIS.
* Ossification of Iliac apophasis

If greater than 3, we ... brace them. (there’s not much growing left to do)

Back 33

Rissers
won’t

Front 34

... is most effective and most commonly used
*... Brace: Cervicothoracolumbosacral orthosis
*... Brace: Thoracolumbosacral orthosis

-In growing children, progression can be arrested, but not ... with a body brace
-Brace when curves are flexible, skeletally immature, between 25-40° or when progressive
-Most effective in Risser 0,1,2 and apex at T-8 and below

Back 34

Orthosis
Milwaukee
Boston
improved

Front 35

Milwauke CTLSO if apex at or above ...
Boston TLSO if apex at or below ...

Full-time wear of 16-23 hours until skeletal maturity, then wean off for 6-12 months: Brace Success is 80%

Expect an initial 40-50% improvement, followed by a gradual loss with the end result = curve at presentation

Back 35

T-7
T-8

Front 36

Surgery:

Indications:
-When underlying abnormality is painful and can be treated
-When rapid progression is occurring on an immature spine
-When the curve is > ... deg. with a great deal of rotation and translatory shift

Goal:
-Restore the normal contour of the back from both the front view and side view
-To fuse as ... segments as possible and to allow maximal normal rotation

Back 36

40
few

Front 37

Surgery:

... Spinal Instrumentation with Fusion:
-Has been used for over 35 years with success
-Gold Standard for majority of thoracic and double major curves
-Loss of lordosis or fusion with instruments below ... is a risk factor for significant low back pain (try not to fuse below this)
-Post fusion radiographs show < in Cobb Angle of around 35%

Back 37

Posterior
L-3

Front 38

surgery:

... Rods: Two rods placed on either side of the spine and anchored to bone by hooks with sequential distraction of concavity and compression of convexity

... Systems: Help maintain lumbar lordosis and thoracic kyphosis

...: Combined with posterior systems for selected indications such as adult scoliosis and high degree curves with rotation

Back 38

Harrington
Segmental
Pedicle Screws

Front 39

Surgery:

... Spinal Fusion with Instrumentation
-Select thoracolumbar curves with apex at T-11,12 and L-1
- Difficult Lumbar curves of 40-60°
-... phenomenon- continued anterior growth under a solid posterior fusion
- ASF with PSF if severe deformation >75° and ... prevention
- (girls <10 years, boys< 13 years)

Advantages: Decreased levels of fusion while sparing lower lumbar levels

Disadvantages: Increased lumbar kyphosis, thoracic hyperkyphosis, rod
breakage(pseudoarthrosis)

Back 39

Anterior
Crankshaft
crankshaft