SPINE DEFORMITY

B Y:
S U P ER V IS O R :
DR. KARYA TRIKO BIAKTO, SP.OT (K) SPINE

ORTHOPEDIC DAN TRAUMATOLOGY

FACULTY OF MEDICINE HASANUDDIN UNIVERSITY
MAKASSAR
2015

AN ATO M Y

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition.

Philadelphia: Elsevier Saunders.

AN ATO M Y

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition.

Philadelphia: Elsevier Saunders.

AN ATO M Y

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition.

Philadelphia: Elsevier Saunders.

ARTERIES O F SPIN E

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition.

Philadelphia: Elsevier Saunders.

Vein ofSpine

1. Thompson JC. Netters Concise Orthopaedic Anatomy. Second Edition.

Philadelphia: Elsevier Saunders.

Balance curves ofthe norm alspine

Feeman B. Scoliosis and Kyphosis. In: Canale Terry S. Campbells

Operative Orthopaedics. 10th Edition. Volume One. Philadelphia: Elsevier.

SPIN AL D EFO RM ITIES

Scolios
is
Kyphosi
s

Affect predominantly
the coronal plane

Affecting sagittal
plane

Reality: Spinal deformities are complex and

simultaneously afect the sagittal, coronal,
axial plane

3. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics

and Fractures. Ninth Edition. UK: Hodder Arnold. 2010. p. 453-70.

K Y P H O SIS
- Normal spine profile of the thoracic region of the
spinal column
- Normal range of thoracic kyphosis: 20-50 degrees
(Cobb angle from T3 to T12)

Greater than 50 degrees:

HYPERKYPHOTIC
3. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics
and Fractures. Ninth Edition. UK: Hodder Arnold. 2010. p. 453-70.

Causes ofKyphotic

4. Devlin Vincent. Spine Secret Plus. Second Edition. Missouri: Elsevier

mosby. 2012. P. 10-7, 34-45, 52-8

A tall teenager with postural thoracic hyperkyphosis

and lumbar hyperlordotic3

Classifi
cation

Postural
kyphosis

Structural
kyphosis

Correctable
The sagittal contour
normalizes because the
deformity is flexible

Fixed and associated with

changess in the shape of
vertebrae
Due to congenital vertebral
defects

Classifi
cation
Congeni
tal
kyphosis

Failure of formation (Type I)

Failure of segmentation (Type
II)
Combination

Adolesc
ent
Kyphosis

Scheuermanns Disease is
defined as three consecutive
levels of at least 5 degrees of
segmental kyphosis (anterior
wedging) at each level

Scheuerm anns D isease

The cause is probably multifactorial
Scheuermann: avascular necrosis necrosis

of the ring apophysis of the vertebral body.

Bick and Copel: disturbance in the ring
apophysis should not affect growth of the
vertebra or cause vertebral wedging.
Aufdermaur and Spycher suggested that a
biochemical abnormality of the collagen
and matrix of the vertebral endplate
cartilage may be important in the etiology

Etiology

ClinicalFindings
Starts at puberty
Affects boy more than girls
Backache and fatigue, sometime

increase after the end of growth and

may become severe
Marked hump
Movements are normal but tight
hamstring often limit straight leg
raising.

Figure 6. A young girl with marked exaggregation of the usual thoracic

kyphosis. X-ray examination show the typical indentations in the vertebral
end plates and wedging of vertebral bodies. 3

PhysicalExam ination
Angular thoracic or thoracolumbar

kyphosis with compensatory hyperlordosis

of lumbar spine
Sharply angular and doesnt correct with
the prone extension test
The lumbar lordosis below the kyphosis
usually is flexible and corrects with forward
bending.
Apparent when viewing the patient from
the side, and the deformity is increased on
the Adam forward bend test

PhysicalExam ination

Adam forward bend test.

Angulated spine profile seen in patient with Scheuermanns disease

RadiologicalFindings
The criteria for the diagnosis :

more than 5 degrees of wedging of

at least three adjacent vertebrae at
the apex of the kyphosis and
vertebral endplate irregularities with
a thoracic kyphosis of more than 45
degrees.

RadiologicalFindings
On a lateral view made with patient

standing, the degree of wedging is

measured by drawing a line along
the superior and inferior endplates of
each vertebral body and measuring
the angle of intersection
There may also be small radioluscent
defects in the subchondral bone
(Schmorls node), which are thought
to be due to central (axial) disc

RadiologicalFindings
Lumbar
Scheuerm
anns
disease

Schmorls
node

Treatm ent
Non operative

Operative

Curves of 40 degrees
or less
Exercises and postural
training
Follow up with repeat
standing lateral
roentgen every 4 to 6
months
Thoracic type (T6-T8)
more than 500 :
Milwaukee brace

Deformity cant
controlled by brace
patients with a very
rigid kyphosis of more
than 800
Lowe: adults with a
kyphosis of 75
degrees or more and
persistent disabling
pain despite
conservative
management

Treatm ent

Operative correction and fixation with Wisconsin rods, bone

grafts were added and can be expected to produce fusion after
3

Sequele
Backache
Embarrassment about physical

appearance
Interruption of work or disability
Severe progressive deformity
Cardiopulmonary failure
Spondylysthesis
Disc degeneration

D iff
erentialD iagnosis
Postural round back deformities
Spondylitis
Osteochondrodystrophies
Ankylosing spondylitis

S C O LIO S IS

D efi
nition
Scoliosis is an apparent lateral

(sideways) curvature of the spine

The commonest form is triplanar

deformity : lateral, anteroposteriorand

rotational components.
Two types of deformity : postural and

structural

PosturalScoliosis

(a) This young girl presented with thoracolumbar curvature.

When she bends forwards, the deformity disappears; this is typical
of a postural or mobile scoliosis. (b) Short-leg scoliosis disappears
when the patient sits. (c) Sciatic scoliosis disappears when the
prolapsed disc settles down or is removed

StructuralScoliosis

Figure (a) Slight curves are often missed on casual inspection

but the deformity becomes apparent when the spine is flexed
(b). The young girl in (c) has a much more obvious scoliosis
and asymmetry of the hip but what really worries her is the
prominent rib hump, seen best when she bends over(d).

Epidem iology
The incidence is approximately 1% in

the general population

Children of women with scoliosis >
(particularly in the daughters of
these women)
The most common type is idiopathic
scoliosis
Scoliosis may occur at any age.
The most common age at diagnosis
of idiopathic scoliosis is 11-13 years.

Etiology (classifi
cation by its
cause)

ClinicalFinding
Deformity : an obvious skew back or

a rib hump in thoracic curves, and

asymmetrical prominence of one hip
in thoracolumbar curves
Pain is a rare complaint (alert the

clinician to the possibility of a neural

tumour)

P hysical exam ination

The history should include :
the age when the deformity was first

noted;
the manner in which it was noted;
the perinatal history; developmental
milestones; other illnesses;
and family history of scoliosis or
other diseases that may affect the
musculoskeletal system

 Inspection
The trunk should be completely exposed ,

examined from in front, from the back and from

the side.
Inspect the skin over the entire spine for
dimples, hair, or vascular markings, which may
signal an underlying congenital anomaly.
Examine the patient, while he or she is standing,
to see shoulder, rib, and hip asymmetry.
In patients with scoliosis, the shoulders or pelvis
may not be level, or waist asymmetry may be
noted. Most commonly, these patients have
scapular prominence, with rotational deformity
and rib prominence.

 Asked the patient to bend forward at

the waist until the shoulders and hips

are in the same axial plane

The rotational deformity of scoliosis is manifested by a rib

hump, which is accentuated by having the patient bend
forward

 Measurement of decompensation

by dropping a plumb bob

from the prominence of
the C7 spinous process
and measuring where it
falls with respect to the
gluteal line.

 Neurologic Tests

Demonstrate a normal gait and be able to

walk on their toes and heels
Motor and sensory testing of the lower
extremities should be performed, and testing
of the upper extremities should also be done
if neuromuscular condition is suspected.
Reflexes should be tested, and the
presence of asymmetry or a pathologic reflex
suggest a non idiopathic etiology.

IM A G IN G STU D IES
X-Ray
In younger patients, special attention is

paid to the pelvis on the P/A x-ray to assess

skeletal maturity by Risser Classification

Risser grade 1 patients have ossified only 25% of their iliac apophysis.
Risser grade 4 patients have ossified 100% of their iliac apophysis, but
have not fused their iliac wing to their ileum. Risser grade 5 patients are
skeletally mature and have ossified their entire iliac apophysis and fused
their iliac wing to the ileum

 Curvature

Measurement
Measurement of the Cobb
angle. End vertebrae are
the last levels that are
tilted into the curve
concavity. A line is drawn
from
the
superior
endplate of the superior
end vertebral body, and
another line is drawn from
the inferior endplate of the
inferior vertebral body The
angle of the intersection of
these lines is the Cobb
angle.

the results of multiple studies done to assist in predicting the

risk of curve progression in adolescents

P R O G N O SIS A N D
TR EATM EN T
Prognosis is the key to treatment.

The aim is to prevent severe

deformity. Generally speaking, the
younger the child and the higher the
curve the worse is the prognosis.
Management differs for the different

types of scoliosis, which are consider

later

ID IO PATH IC SC O LIO SIS

Infantile Idiophatic Scoliosis

Infantile idiopathic scoliosis is a

structural, lateral curvature of the

spine occurring in patients younger
than 3 years of age
More frequent in boys than in girls,

and were primarily thoracic and

convex to the left

Etiology and ClinicalFinding

Etiological factors of infantile idiopathic

scoliosis are multiple, with a genetic

tendency that is either triggered or
prevented by external factors
Mental retardation in 13%, inguinal

hernias in 7.4% of boys with progressive

scoliosis,congenital dislocation of the
hip in 3.5%, and congenital heart
disease in 2.5% of all patients

A girl age 2 years + 9 months who presented with severe

infantile onset idiopathic scoliosis

Treatm ent
(1) serial casting, progressing to

bracing and later fusion,

(2) preoperative traction to correct
the curve followed by fusion, and
(3) subcutaneous instrumentation
without fusion.

Juvenil Idiophatic Scoliosis

Juvenile idiopathic scoliosis appears

between the ages of 4 and 10 years.

The characteristics of this group are

similar to those of the adolescent

group.
Convexity of the thoracic curve

usually is to the right.

TREATM EN T
For curves of less than 20 degrees,

bservation is indicated, with

examination and standing
posteroanterior roentgenograms
every 4 to 6 months

A dolescent Idiophatic Scoliosis

The characteristics of adolescent

idiopathic scoliosis : a threedimensional deformity of the spine

with lateral curvature plus rotation of
the vertebral bodies.

Etiology

Possible interrelationships of various factors that

have been shown to have possible role in cause of
idiopathic scoliosis

TREATM EN T
NON OPERATIVE

If the patient is approaching skeletal

maturity and the deformity is acceptable
(which usually means it is less than 30
degrees and well balanced), treatment is
probably unnecessary unless sequential xrays show definite progression.
Bracing has been used for many years
in the treatment of progressive scoliotic
curves between 20 and 30 degrees

Operative Treatment
Surgery is indicated:
(1) for curves of more than 30 degrees
that are cosmetically unacceptable,
especially in pre-pubertal children who
are liable to develop marked
progression during the growth spurt;
(2) for milder deformity that is
deteriorating rapidly.

CO N G EN ITAL AN O M ALIES
Congenital scoliosis is a lateral curvature of the

spine caused by the presence of vertebral

anomalies that result in an imbalance of the
longitudinal growth of the spine
The cause of congenital vertebral anomalies

remains
unknown.
During
embryologic
development, these abnormalities develop in
the spine between the fifth and eighth weeks of
gestation, but it is very uncommon to identify
any traumatic or teratologic type of maternal
insult during this stage of pregnancy.

CLASSIFICATIO N

PhysicalExam ination
The skin of the back should be

carefully examined for signs such as

hair patches, lipomata, dimples, and
scars, which may indicate an
underlying anomalous vertebra
The neurological evaluation should

be very thorough

Hair patch associated with

diastematomyelia and
congenital scoliosis

TREATM EN T
Treatment is more difficult and specialized than
that of idiopathic infantile scoliosis. Progressive
deformities (usually involving rigid curves) will
not respond to bracing alone, and surgical
correction carries a significant risk of cord injury.
These children should be treated in special units:
the approach is to undertake staged resection of
the curve apex, followed by instrumentation and
spinal fusion. If multiple segments of the spine
are involved, surgery may be too hazardous and
should probably be withheld.3

N EU RO M U SCU LAR SCO LIO SIS

Neuromuscular conditions frequently

associated with scoliosis include

muscular dystrophy, cerebral palsy,
poliomyelitis, spinal cord tumor,
spinal cord trauma, spinal muscular
atrophy,
Friedreich
ataxia,
syringomyelia,
familial
dysautonomia,
and
myelomeningocele

ETIO LO GY

CLIN ICAL FIN D IN G

Spinal deformities tend to present early in life in patients with

these conditions and often progress to severe deformities

because of muscle weakness and the many years of ensuing
growth. The assessment of patients should be detailed and
include an evaluation of overall function, mental status, motor
strength, ambulatory status, and sitting tolerance as well as a
search for the presence of problems such as joint contractures,
pelvic obliquity, and pressure sores. Joint contractures can lead
to pelvic obliquity or can limit the patient's ambulatory or sitting
ability.
Pelvic obliquity or a dislocated hip can be primary and lead to

scoliosis or can be secondary to the spinal deformity. The

primary condition should be determined, and if corrected
sufficiently early, may obviate or delay the need for further
corrective surgery.8

TREATM EN T
Treatment depends upon the degree of functional

disability. Mild curves may require no treatment at

all.
Moderate curves with spinal stability are managed
as for idiopathic scoliosis.
Severe curves, associated with pelvic obliquity
and loss of sitting balance, can often be managed
by fitting a suitable sitting support. If this does not
suffice, operative treatment may be indicated.
This involves stabilization of the entire paralyzed
segment by combined anterior and posterior
instrumentation and fusion.

REFEREN CE
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2. Feeman B. Scoliosis and Kyphosis. In: Canale Terry S. Campbells Operative Orthopaedics. 10 th Edition.
Volume One. Philadelphia: Elsevier. 2003.
3. Solomon L, Warwick D, Nayagam S. Appleys System of Orthopaedics and Fractures. Ninth Edition. UK:
Hodder Arnold. 2010. p. 453-70.
4. Devlin Vincent. Spine Secret Plus. Second Edition. Missouri: Elsevier mosby. 2012. P. 10-7, 34-45, 52-8
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2007.p.372-5
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