paralytic and postural scoliosis

MODERATOR:PROF.DR.K.PRAKASAM

M.S.Ortho,D.Ortho,DSC (HON)

Director & HODPRESENTOR:DR.THOUSEEF.A.MAJEED

paralytic & Postural Scoliosis

INTRODUCTION

• “Scoliosis” - Greek word meaning “crooked.”

• It is a lateral curvature of the spine in upright position.

• The Scoliosis Research Society has defined scoliosis

as a lateral curvature of the spine greater than 10

degrees as measured using the Cobb method on a

standing radiograph.

• Triplanar deformity of lordosis,

rotation & lateral wedging of

vertebrae.

• It produces body

disfigurement.

• When deformity is extreme it

compresses viscera and reduces

life expectancy of the patient.

“Normal” alignment

• Spinous processes all line up in a

straight line over the sacrum

Scoliosis is a combination of

• Angular displacement

• Lateral displacement

Spinal Biomechanics

Lateral displacement • Angular displacement

• Paralytic scoliosis is defined as the increased

lateral curvature of the spine due to paralysis of

spinal muscles.

PARALYTIC SCOLIOSIS

• Curve is long, convex towards the side with weaker muscles

( spinal, abdominal or intercostal) & at first mobile

• Rapid progression of the curve due to asymmetrical

paralysis.

• Loss of stability & balance which makes sitting difficult in

severe cases

• Loss of sensibility causes pressure ulceration

• Respiratory insufficiency

• Pelvic obliquity

Classification

• NEUROPATHIC • MYOPATHICNeuropathic• Poliomyelitis Lower motor neuron• Traumatic• Spinal muscle atrophy• Dysautonomia

• Cerebral palsy

• Friedreich ataxia

• Charcot Marie Tooth

• Syringomyelia

• Spinal cord tumour

• Spinal cord trauma

Upper motor neuron

MYOPATHIC

• Arthrogryposis

• Muscular dystrophys

• Congenital hypotonia

CURVE PATTERNS IN PARALYTIC SCOLIOSIS

• Thoracic • Thoraco-lumbar • Lumbar• Combined thoracic and lumbar • The side towards which the

convexity of the curve is directed is designated as Right or Left.

• The curve may take some years to develop

• It gives a paraylitic curve with long, convex

towards the side with weaker muscles.

(spinal,abdominal or intercostal)

• Pelvic oblquity develops due to muscle

imbalance .

• Loss of muscle strength or voluntary muscle

control and loss of sensory abilities in the

flexible and rapidly growing spinal column

results in these curve development.

• Rapid progression in the curvature (12-16

years)

• Deformity is usually the presenting symptom

• Pain is rare complaint

• long C-shaped curve

• Rib hump or abnormal para spinal muscular prominence

indicates spinal rotation

• Rib hump leads to asymmetry of trunk called angle

trunk rotation (ATR) .

CLINICAL FEATURES

TREATMENT OF PARALYTIC SCOLIOSIS

Conservative

• Conservative is preferred initially up to 10 years

of age.

• Fitting a suitable sitting support.

• Halo femoral traction

• Milwaukee brace

Surgical treatment

• Indicated after 10 years

• Failed conservative treatment

• Curve is progressing inspite of conservative treatment

• High cervico dorsal curves

• Patients with cardiopulmonary insufficiency due to

scoliosis

• Stabilization of entire paralysed segment by

combined anterior & posterior fusion.

o When paralysis of the trunk is extensive -fusion is

best done in stages.(T1-L3 or L4).

o Pelvis is included in fusion if pelvis is tilted and

forms a component part of the primary curve

• The treatment of scoliosis with pelvic obliquity

varies according to the location.

1. Distal to the iliac crest

2. Proximal to the iliac crest

3. Above and below the crest

Distal to the iliac crest

Hip flexion-abduction contracture

• Stage I :Surgical release of flexion abduction

contracture.

• Stage II :Scoliosis is then treated as an

independent problem

Proximal to the iliac crest

• Correct obliquity and scoliosis together.

• Fusion to maintain correction .

• Fusion must extend to the sacrum

Above and below the crest

• Both deforming elements must be

corrected(obliquity and scoliosis)

• Fusion must include sacrum

Scoliosis in polio myelitis• Asymmetrical paralysis of paraspinal muscles.

• May affect any part of the spine

• 5% of poliomyelitic patients affect scoliosis.

• The muscle imbalance is the cause for developing

scoliosis.

• When paralysis is extreme and symmetrical ,

scoliosis may not develop

Spinal curvature is divided into two types

• 1.Convexity of curve towards stronger muscle

groups (eg:the ilio psoas, the sacrospinalis and the

quadratus lumborum)

• 2.Concavity towards stronger muscle groups.

(eg:the abdominalis ,the sacro spinalis and the

quadratus lumborum)

• Contracture of the pelvi trochanteric muscles

and the iliotibial band with resultant pelvic

obliquity deviates the spine towards that side.

• Neurological element also result in structural

changes in the spine.

• Long C type of curve

• Appearance of curve with in 10 years of age and progress in

adulthood.

• Rapid progression in the curvature(12-16years)

• 15° or more occurring before the age of 11 should be

viewed with a high index of suspicion for underlying intra

spinal pathology.

3 Major types of poliomyelitic scoliosis

• High Cervicodorsal kyphoscoliosis

• Long Dorsolumbar scoilosis

• Lumbar Scoliosis

Treatment for poliomyelitic scoliosis

• Conservative treatment

• Surgical treatment

Conservative treatment

• Prolonged recumbancy 6 months in paralysis

of trunk and abdominal muscles.

• Lying on a concave frame favours weak

abdominalis muscle

• Spine should be evaluated every 3months by

standing radiographs.

• Postpoliomyelitic scolotic brace

• On begining of ambulation ,if asymmetry of

abdominalis and hip muscles exists then the use of

crutches with a tripod gait is necessary

• Halo –femoral traction should be avoided because it

may produce additional osteoporosis

Surgical indication in poliomyelitic scoliosis

• Collapsing spinal deformity

• Spinal deformity does not respond to nonoperative

treatment.

• Reduction of cardio respiratory function .

• Back pain and loss of sitting balance with increased

pelvic obliquity

•

Surgical treatment for poliomyelitic scoliosis

• Early fusion should de avoided

• Many paralytic curves becomes stable and static

and require no fusion.

• Pelvic obliquity = Iliotibial band resection

• Abdominal & Quadratus lumborum = Fascial

transplants.

For high cervico thoracic curves

• Scapular elevator muscles, two strips of fascia are

attached to the scapular spine

• one strip to the cervical muscles at the apex of the

curve on the concave side.

• The other strip to the spinous process of the first

thoracic vertebra

Rhomboids and levator scapulae paralysis

• These muscles normally pull the scapula upward

and inward and exert tension on the cervical and

upper 4 thoracic vertebrae.

• Paralysis causes the pull of spine to opposite side.

• Facial transplants are attatched to the vertebral

border of scapula and into the spinal muscles & the

latismus dorsi

• Long fusion is necessary to result in a

balanced spine.

CEREBRAL PALSY SCOLIOSIS

• Most often thoraco lumbar curve

• Pelvic obliquity & hip contracture present

• Progressive curve of any degree depends on

the degree of neuromuscular inolvemnt.

• Normal mortality

Clinical features

• Thoracolumbar curve is common

• Unlike idiopathic scoliosis scoliosis produced

by cerebral palsy may be painful.

• Sitting may be more difficult due to increase in

pelvic obliquity.

Goals of scoliosis treatent in Cerebral Palsy ----Bonnette etal

• Improvement in assisted sitting.• Relieve the pain from back and hip.• Increased independence because decreased

need for assistance.• Improvement in upper extremity function and

table top up activities

Classification

• Lonstein and Akbarnia classified cerebral palsy into two groups.

• Group I curves

• Group II curves

Group I Curve

• Double curves

• Both thoracic and lumbar components

• Similar to the curves of idiopathic scoliosis.

• Commonly occurs in ambulatory patients with

mental retardation.

Group II

• Thoracolumbar curves that extend to the

sacrum with marked pelvic obliquity

• Patients with this curve are non ambulatory

with spastic quadriplegia

• Best managed by early recognition and control of

the curve before the deformity becomes severe.

• Seating is the most common non-operative form .

• The orthoses of choice is a total contact

thoracolumbosacral orthosis (TLSO) Or soft boston

orthosis.

Treatmentof Cerebral palsy Scoliosis

• Curve >50 degree requires surgical correction.

For severe lumbar and thoraco lumbar curves

• Stage I :Anterior fusion with Dweyer’s

instrumentation over apical area.

• Stage II : After 2 weeks

• Posterior fusion with Harington Rods etending to

the sacrum.

• Upper limit of fusion should be above T4

Surgical Complications of cerebral palsy scoliosis

• Increased risk of infection

• Pulmonary complications (cannot co operate

in deep breathing ).

• Kyphosis cephalad to the upper limit of

fusiona.

Scoliosis in Arthrogryposis congenita

• Syndrome of persistent joint contractures at birth

• Scoliosis may develop from birth itself.

• Common pattern is thoracolumbar curve.

• Associated with pelvic obliquity and lumbar

hyperlordosis.

• Curves are progressing according to age and

becomes rigid and fixed

Classification

• Subtype I:Myopathic- characterised by muscle

changes

• Subtype II: Neuropathic-anterior horn cells are absent

or reduced in cervical, thoracic and lumbosacral

segments .

• Subtype III: joint fibrosis and contractures alone.

Treatment of arthrogrypotic scoliosis

• Brace treatment rarely successful and should be used

in patient with small flexible curve and curve of less

than 30 degree.

• Pelvic obliquity can be treated by release of

contractures in the hip area .

• If the scoliosis not corrected by release of

contractures spinal fusion to the sacrum is necessary

Surgeries for arthrogrypostic scoliosis

• Harrington instrumentation and posterior fusion.

• Combined anterior and posterior spinal arthrodesis.

FRIED RICH ATAXIA• Recessively inherited condition characterised by spinocerebellar

degeneration

• Onset 6-20 years of age

Characterised by

• Ataxic gait

• Dysarthria

• Muscle weakness

• Lack of deep tendon reflexes

• Decreased proprioception

Secondary symptoms include • Pes cavus• Scoliosis• Cardiomyopathy• The most common pattern is double structural

thoracic and lumbar curves.• Pelvic obliquity may present.

Treatment for spinal muscle atrophyOrthotic treatment :

• skeletally immature patient with 20 degree curve.

• TLSO(thoraco lumbo sacral orthosis) .

• Chest wall deformities are contraindication for orthotic

treatment.

Surgical treatment

• by posterior spinal fusion with instrumentation and

bone grafting.

• For a fixed lumbar curve with pelvic obliquity

anterior release and fusion may be needed in

addition to posterior instrumentation.

• After surgery ventilator support may be

necessary due to pulmonary complications.

FAMILIAL DYSAUTONOMIA• Rare autosomal recessive disorder• Commonly seen in jewish chidrenCharacterised by • Overflow of tears• Sweating • Vasomotor instability– hypothermia• Dysrthria• Dysphagia • Motor incordination• Scoliosis and Kyphosis

• Progressive type of curve• In this patients early death is due to

kyphoscoliotic cardiopulmonary decompensation.

• Scoliosis can be conservatively managed by Milwaukee brace.

• Surgery :Posterior spinal fusion with instrumentation

POSTURAL SCOLIOSIS (MOBILE SCOLIOSIS)

• The scoliosis deformity is secondary to some

condition outside the spine .(short leg ,pelvic tilt)

• When the patient sits the curve disappears. (non

structural)

• Occurs in late years of first decade of life

Causes for postural scoliosis

• Short leg

• Pelvic tilt

• Local muscle spasm with a prolapsed lumbar disc

• Sciatica-Sciatic Scoliosis.

Treatment • Depends on the degree of functional disability.

• Mild curves may require no treatment

• Moderate curve with spinal stability are managed as same as

idiopathic scoliosis

• Severe curves with pelvic obliquity and loss of sitting

balance managed by proper sitting support.

• If this fails operative treatment is indicated.

• Surgery involves the stabilization of the entire paralysed

segment by combined anterior and posterior

instrumentation and fusion.