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Spinal Deformities
Dr. Budak Akman
T.C Yeditepe University Orthopaedics and
Traumatology
Physical Examination of
Spine
Fizik Muayene
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İnspeksiyon
Palpasyon
Hareket açıklığı
Tendon refleksleri
Nörolojik Muayene
İnspeksiyon
• Asimetri - Pelvik Oblisite
– Pelvik rotasyon, alt ekstremitede uzunluk farkı
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Lordoz veya kifoz artışı
Skolyoz
Café au lait spotları-nodüller
Kıllanma – kırmızı şarap lekesi
Yürüyüş muayenesi
Palpasyon
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Spinöz proçeslerde basamak
Paraspinal Adale spazmı – pozisyon
Lokal hassasiyet noktaları
Tetik noktaları
Sakroiliak eklem muayenesi
ROM (=Hareket açıklığı)
• Öne fleksiyon :
Parmak ucu yer mesafesi
ölçümü (N:10cm)
• Ekstansiyon :
Lordoz artışı (değişik
derecelerde) (N:20˚-30˚)
• Lateral fleksiyon :
Parmak uçlarının diz
eklemine göre
pozisyonları (N:20˚-30˚)
Nörolojik Muayene
• Motor (spastisiteye dikkat)
• Duysal (hafifçe dokunma ve
iğne batırma)
• Refleksler
L3, S1, S2-4, Babinski
DUYU-MOTOR
DERMATOM
DUYU TESTİ
MOTOR TEST
REFLEKS TESTİ
Anteromedial
uyluk
İliopsoas
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L3
Patella proksimali
Quadriceps
Patella refleksi L3
L4
Kruris-ayakbileği
mediali
Tibialis anterior
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L5
Krurisin lateraliayak dorsali
Ekstansör Hallucis
longus
S1
Baldır posteriorutopuk
Gastrosoleus
S2
Femur posterioru
Rektal
kontraksiyon
Perianal bölge
Rektal
kontraksiyon
L1-L2
S3-S4-S5
Aşil refleksi S1
Özgül Testler
• Düz bacak kaldırma
• Çapraz düz bacak
kaldırma testi
• Laseque testi
• Valsalva Manerası
• Femoral GermeTesti
L5-S1
L3-L4
SPONDYLOLYSİS AND SPONDYLOLİSTHESİS
• Spondylolysis and Spondylolisthesis
– Etiology
• Spondylolysis refers to degeneration of the vertebrae due to congenital
weakness (stress fracture results)
• Slipping of one vertebrae above or below another is referred to as
spondylolisthesis and is often associated with a spondylolysis
– Signs and Symptoms
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Spondylolysis begins unilaterally
Pain and persistent aching, low back stiffness with increased pain after activity
Frequent need to change position
Full ROM w/ some hesitation in regards to flexion
Localized tenderness and some possible segmental hypermobility
Step off deformity may be present
SPONDYLOLYSİS AND SPONDYLOLİSTHESİS
CLASSIFICATION
Congenital:Congenital dysplasia of facet joınt L5-S1
Isthmic: Defect of Pars interarticularıs (EN SIK)
Degenerative: facet arthrosis leading to
subluxation
Traumatic: Acut
Pathologic: Tm, enfection, paget disease…
Post surgical: iatrogenic
Spondylolysis and Spondylolisthesis
Spondylolysis and Spondylolisthesis
Spondylolysis and Spondylolisthesis
– Management
• Bracing and occasionally bed rest for 1-3 days will help
to reduce pain
• Major focus should be on exercises directed as
controlling or stabilizing hypermobile segments
• Progressive trunk strengthening, dynamic core
strengthening, concentration on abdominal work
• Braces can also be helpful during high level activities
• Increased susceptibility to lumbar strains and sprains
and thus vigorous activity may need to be limited
Spinal Deformities
Spinal Deformities
• Spinal deformities occur in either coronal or
sagittal plane
What is scoliosis?
• Lateral curvature of the spine >10º
accompanied by vertebral rotation
• Idiopathic scoliosis - Multigene dominant
condition with variable phenotypic
expression & no clear cause
• Multiple causes exist for secondary
scoliosis
Scoliosis classification
1-Structural:
Idiopatic
Congenital
neuromuscular
Neurofibromatosis
Osteochondrodystrophyos
Metabolic
2-Non-structural:
(postural, histeric, herniopaty)
Idiopathic Scoliosis
“Classification”
• Age at Onset:
Infantile: age birth to 3 years
Juvenile: age 4 to 10 years
Adolescent: age 11 to 17 years
Adult: age 18 years up
Idiopathic Scoliosis
“Etiology”
• Remains unknown
• Several studies have attempted to look into
this and various factors have been
postulated: genetic, tissue deficiencies,
vertebral growth abnormalities, and central
nervous system theories
Idiopathic Scoliosis
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“Genetic Factors”
Risenborough found a 11.1% incidence of
scoliosis in first born relatives of patients
with idiopathic scoliosis
Twins show a concordance of scoliosis with
an incidence of 92% monozygotic and 63%
dizygotic
Secondary causes for scoliosis:
Inherited connective tissue disorders
- Ehler’s Danlos syndrome
- Marfan syndrome
- Homocystinuria
Secondary causes for scoliosis:
Neurologic disorders
• Tethered cord
syndrome
• Syringomyelia
• Spinal tumor
• Neurofibromatosis
• Muscular
dystrophy
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Cerebral palsy
Polio
Friedeich’s ataxia
Familial
dysautonomia
• Werdnig-Hoffman
disease
Secondary causes for scoliosis:
Musculoskeletal disorders
»Leg length discrepancy
»Developmental hip
dysplasia
»Osteogenesis
imperfecta
»Klippel-Feil syndrome
Characteristics of idiopathic scoliosis:
• Present in 2 - 4% of kids aged 10 – 16
years
• Ratio of girls to boys with small curves
(<10º) is equal, but for curves >30º the
ratio is 10:1
• Scoliosis tends to progress more often
in girls (so girls with scoliosis are more
likely to require treatment)
• Toracal curve (right)
• Lomber curve (left)
Natural history of scoliosis
• Of adolescents diagnosed with scoliosis,
only 10% have curve progression requiring
medical intervention
• Three main determinants of curve
progression are:
(1) Patient gender
(2) Future growth potential
(3) Curve magnitude at time of diagnosis
Natural history of scoliosis
Assessing future
growth potential
using Tanner
staging:
Tanner stages 2-3 (just
after onset of pubertal
growth) are the stages
of maximal scoliosis
progression
Natural history of scoliosis
Assessing growth potential using Risser
grading:
- Measures progress of bony fusion of iliac
apophysis
- Ranges from zero (no ossification) to 5
(complete
bony fusion of the apophysis)
- The lower the grade, the higher the potential
for
progression
Line Of Risser
Risser 2
Risser 1 = 25% Capping.
Risser 2 = 50% Capping.
Risser 3 = 75% Capping.
Risser 4 = 100% Capping.
Risser 5 = 100% Capping + Fusion.
RİSSER 4
Natural history of scoliosis
• Back pain not significantly higher in pts with
scoliosis
• Curves in untreated adolescents with curves
< 30 º at time of bony maturity are unlikely to
progress
• Curves >50 º at maturity progress 1º per year
• Up to 19% of females with curves >40 º have
significant psychological illness
• Life-threatening effects on pulmonary
function do not occur until curve is >100 º (ie:
Cor pulmonale)
Adam’s forward bend test
• For this test, the patient is asked to lean forward with
his or her feet together and bend 90 degrees at the
waist. The examiner can then easily view from this
angle any asymmetry of the trunk or any abnormal
spinal curvatures
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Screening hints:
• Shoulders are different heights – one shoulder
blade is more prominent than the other
• Head is not centered directly above the pelvis
• Appearance of a raised, prominent hip
• Rib cages are at different heights
• Uneven waist
• Changes in look or texture of skin overlying the
spine (dimples, hairy patches, color changes)
• Leaning of entire body to one side
• Cavus feet
Red flags on PE:
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Left-sided thoracic curvature
Pain
Significant stiffness
Abnormal neurologic findings
Stigmata of other clinical syndromes
associated with curvature
• Juvenil scoliosis
MRI
Measure spinal curvature using Cobb method:
- Choose the most tilted
verterbrae above & below
apex of the curve.
- Angle b/t intersecting lines
drawn perpendicular to the
top of the
superior vertebrae and
bottom of the inferior
vertebrae is the Cobb
angle.
Measure spinal curvature using Cobb method:
Measure spinal curvature using Cobb method:
Treatment Decisions
DECISION TO TREAT WITH AN ORTHOSIS
TLSO
CTLSO
APICES T8
AND INFERIOR
APICES SUPERIOR
TO T8
Accepted Standards
CTLSO
TLSO
Brace Treatment for Scoliosis
• Most common is Boston
brace
• Braces have 74% success
rate at halting curve
progression (while worn)
• Bracing does not correct
scoliosis, but may prevent
serious progression
• Usually worn until patient
reaches Risser grade 4 or 5
Brace Treatment for Scoliosis
• Of patients with 20 º - 29 º
curves, only 40% of those
wearing braces ultimately
required surgery,
compared to 68% of those
not wearing back braces
• Length of wearing time
correlates with outcome (At
least 16 hrs per day leads
to best chance of
preventing curve
progression)
Idiopathic Scoliosis
SURGICAL CORRECTION GOALS
Reduce the magnitude of the curve
Obtain fusion to prevent progression
Create a well-balanced spine
Idiopathic Scoliosis
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SURGICAL CORRECTION INDICATIONS
Curves over 45 degrees
Trunk deformity(rotation)
Trunk balance
Progressive curves despite bracing
Congenital scoliosis
Neurologic symptoms
Idiopathic Scoliosis
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GENERAL GUIDELINES FOR TREATMENT OF
SCOLIOSIS
Under 20 degree’s: observe
20 to 30 degree’s: observe with frequent
follow-up; progression then brace
30 to 45 degree’s: brace unless Risser 4/5 then
observe
45 plus degree’s: instrumentation
Scoliosis treatment plan
Curve
Risser
Therapy
0-25
Immature
observe
25-30
immature
brace
30-45
immature
brace
>45
immature
surgery
>50
mature
surgery
Surgical Treatment for Scoliosis
• Curves in growing children greater than 40 º
require a spinal fusion (Risser grade 0 to 1 in
girls and Risser 2 or 3 in boys)
• Skeletally mature patients can be observed until
their curves reach 50 º
• Posterior spinal fusion is best choice for thoracic
curves
• Anterior spinal fusion is best treatment for
thoracolumbar and lumbar curves
Surgical Treatment for Scoliosis
Scoliosis
• Adolescent idiopathic scoliosis
• Structural scoliosis presenting at or
about the onset of puberty and
before maturity
• 80 % of cases of idiopathic scoliosis
• Mostly (90%) in girls
• Predictors of progression
very young age
marked curvature
Risser sign
Congenital Scoliosis
• Congenital scoliosis
• Due to congenital anomalous vertebral development
Hemivertebrae
Wedged vertebrae
Fused vertebrae
Absent or fused ribs
• Treatment
Early fusion in progressive curves
Congenital Scoliosis
Neuromuscular Scoliosis
• Neuromuscular scoliosis
• Causes
Poliomyelitis
Cerebral palsy
Syringomyelia
Friedrich’s ataxia
Muscular dystrophies
• Typical paralytic curve is long,
convex towards the side with
weaker muscles
Kyphosis
• Postural
• Congenital
• Scheuermann’s
disease
• T1-T12: 20 - 40°
Kyphosis
• Postural
YAPISAL
POSTURAL
Kyphosis
• Congenital
Kyphosis
• Scheuermann’s disease
 Cobb angle >45°
 with wedging of 5 or more of at
least 3 adjacent apical
vertebrae
 vertebral end plate
irregularities
• Etiology :Unknown
• Incidence:1% of general
population with slight female
dominance
Spinal stenoz
Spinal kanalın daralma yolu ile nöral doku
basılarına neden olan klinik durumdur.
Kanal çapında merkezi daralmalar
olabileceği gibi lateral reseslerde de kök
basılarına yol açan sıkışmalar gözlenebilir.
Spinal Stenoz
(Klinik yaklaşım)
• Etyoloji:
– Konjenital daralma
– Spondilolistezis
– Travma
– Yaşlanmaya bağlı
dejeneratif
değişiklikler
– Diğer
• Semptomlar
Etyolojik Yaklaşım
• Konjenital / Edinsel
kanal darlığı
• İdiopatik: pedikül
gelişiminde duraklama
• Spondilolistezis, Paget
hastalığı, Akondroplazi
gibi kemik hastalıklarına
bağlı olarak
gelişebilirler.
Ağrı:
• Ağrı bölgesi (bel,bacak)
• Şikayetlerin tanımlanması:
Uyuşukluk,ağrı,güçsüzlük
• Ağrının tipi
– Ayak ağrısı, saplanır tarzda ağrı, elektriklenme
– Devamlı, fasılalı
• Devamlılık Akut, subakut kronik
• Başlangıç, ani, yavaş, travmatik
Ağrı Dışı Semptomatoloji
• Nörojenik klaudikasyo
• Radikülopati
• İkisinin birlikteliği
Klinik Değerlendirme
• Nörojenik klaudikasyo semptomatik stenozlu
olgularda %50-62 oranında ortaya çıkar. Nörojenik
klaudikasyo klinikte karşımıza bel kalça uyluk ve
baldır ağrısı olarak karşımıza çıkar.
Risk Faktörleri:
• Obezite (3 x risk artışı)
• Sigara (öksürme ile )
• Mesleki zorlanma
– Tekrarlayıcı hareket, vibrasyon veya burulma
hareketi
– Uzun süreli araç kullanımı
– Sedanter yaşam
Spinal stenozun ayırıcı tanısı
• Dejeneratif disk hastalığı
• Faset artropatisi
• Spondilolistezis
• Spondilolizis
• Herniye disk
• Diskojenik ağrı
Radiküler Semptomlar
• Ağrının dağılımı, taraf bulgusu ve niceliği
• Dermatomal ağrı dağılımı veya uyuşukluk ve
sızlama
– L3 or L4 - anterior uyluk ağrısı
– L5 -ayak sırtı ve başparmak
– S1 -posterior baldır, topuk, ayak dış yanı
• Bacak Ağrısı > Bel Ağrısı!
Radiküler Semptomlar
• Artmış ağrı cevabı:
– Fleksiyon
– Oturma
– Öksürme,hapşırma,ıkınma
• Ağrıda azalma:
– Supin pozisyonda yatma
– Dizlerde fleksiyona getirme
– Ayakta durma
Tedavi
• Konservatif tedavi
– FTR
– Korse
– NSAI
– Kilo verme
• Cerrahi tedavi
– Dekompresyon
– Füzyon
THANK YOU