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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
(Left) PA radiograph shows
idiopathic thoracic
dextroscoliosis. The apical
vertebra st is the most
displaced from the midline.
Terminal vertebrae ſt show
the greatest deviation of the
Disorders of Alignment
endplates from the horizontal.
(Right) Lateral radiograph in
the same patient shows
reversal of usual thoracic
kyphosis. Rotational
component of the scoliosis can
be grossly assessed by the
degree of rotation of the ribs
st.
(Left) Axial 3D reformation
allows measurement of the
rotational component of
scoliosis. This is the angle
between the terminal vertebra
ſt and the apical vertebra st.
(Right) Coronal CT
reconstruction shows
measurement of severe
neuromuscular scoliosis. The
scoliotic curvature is the angle
between the vertebrae with
the greatest degree of
inclination from the
horizontal.
Introduction to Scoliosis
140
(Left) PA radiograph shows a
single, long sweeping curve
thoracolumbar scoliosis
typical of neuromuscular
scoliosis. No vertebral
anomalies are present. (Right)
PA radiograph in the same
patient shows only slight
improvement in the curve
when the patient bends to the
right. Lateral bending films or
supine films are used to assess
the flexibility of a scoliotic
curvature. Rigid curves are less
amenable to reduction.
Introduction to Scoliosis
Disorders of Alignment
(Left) Anteroposterior
radiograph shows multilevel
degenerative disc disease and
only minimal leftward
curvature in a 50-year-old
woman. Disc disease is slightly
asymmetric at the apex of the
curve ſt, and facet
osteoarthritis is more
severe on the right (concave)
side. (Right) Anteroposterior
radiograph in the same
patient 4 years later shows
significant curve progression
and progression of the
asymmetric degenerative disc
disease ſt and facet
osteoarthritis.
(Left) Coronal CT
reconstruction fused with
SPECT bone scan shows
abnormal uptake at facet
joint at the concave aspect of
degenerative scoliosis. Fusion
of CT and SPECT is sometimes
useful to pinpoint pain
generators and guide joint
injections. (Right) Coronal
T2WI MR is useful in
evaluating disc and facet
abnormalities in degenerative
scoliosis. In addition, it can be
used as a scout to set angled
images through the
intervertebral discs.
(Left) Axial T2WI MR at the L2L3 level was angled based on
sagittal scout but not in
reference to sagittal images.
The disc is obliquely imaged,
and, even though the scoliosis
was mild, the image appears
distorted. (Right) Axial T2WI
MR at the same level, but
angled with the disc
orientation on the coronal
image, shows an annular
fissure st on the right. Spinal
stenosis appears more severe
because the image is
perpendicular to the canal
rather than oblique as in the
preceding image.
141
Scoliosis
KEY FACTS
TERMINOLOGY
• General term for any lateral curvature of spine (≥ 10°)
IMAGING
• Lateral curvature of spine
○ Returns to midline at ends of curve
○ Rotational component common
Disorders of Alignment
• Most commonly thoracic or thoracolumbar
• Imaging approach
○ Radiography for initial diagnosis
○ Multiplanar MR to screen for bone, cord abnormalities
○ CT for surgical planning, complications
TOP DIFFERENTIAL DIAGNOSES
• Idiopathic scoliosis
• Neuromuscular scoliosis
• Congenital scoliosis
• Scoliosis due to congenital syndromes without vertebral
anomalies
(Left) PA radiograph in an
idiopathic scoliosis patient
shows the typical curve of
idiopathic scoliosis that is
convex to the right in the
thoracic spine and convex to
the left in the lumbar spine.
No vertebral anomalies are
present, excluding congenital
scoliosis. (Right) Lateral
radiograph (idiopathic
scoliosis) depicts the
rotational component of
scoliosis, leading to posterior
position of the ribs on the left.
Thoracic kyphosis is
diminished, another
characteristic finding.
• Degenerative scoliosis
• Scoliosis due to infection
• Scoliosis due to tumor
• Scoliosis due to trauma
• Curvature related to limb length inequality
• Positional scoliosis
CLINICAL ISSUES
• Usually presents in childhood or adolescence
• Idiopathic scoliosis usually asymptomatic
○ Painful scoliosis indicates underlying abnormality
• Surgical fusion for rapidly progressive curves, curves > 40°
DIAGNOSTIC CHECKLIST
• Short-curve or painful scoliosis usually has underlying
abnormalities
• Curve may progress rapidly, especially during growth spurts
142
(Left) Anteroposterior 3D
reformatted bone CT of
idiopathic scoliosis shows
rotation as well as scoliosis to
be present on the apical
vertebra ſt and terminal
vertebrae . (Right) Axial
bone CT 3D reformation
demonstrates the rotation of
the apical vertebra
compared to the terminal
vertebrae ſt. 3D CT is
valuable in surgical planning
to evaluate severity of
rotation.
Scoliosis
TERMINOLOGY
Definitions
• General term for any lateral spine curvature
• Dextroscoliosis: Curve convex to right
• Levoscoliosis: Curve convex to left
• Kyphoscoliosis: Scoliosis with component of kyphosis
• Rotoscoliosis (outdated term): Scoliosis that includes
rotation of vertebrae
• S-curve scoliosis: 3 adjacent curves, 1 to right and 1 to left, 1
at lumbosacral junction
• C-curve scoliosis (outdated term): Long sweeping curvature
• Terminal vertebra: Most superior or inferior vertebra
included in curve
• Transitional vertebra: Vertebra between 2 curves
• Apical vertebra: Vertebra with greatest lateral
displacement from midline
• Primary curvature: Curvature with greatest angulation
• Secondary or compensatory curvature: Smaller curve that
balances primary curvature
IMAGING
General Features
• Best diagnostic clue
○ Lateral curvature of spine that returns to midline at ends
of curve
• Location
○ Most commonly thoracic or thoracolumbar
• Size
○ Curve > 10°
○ May be > 90°
• Morphology
○ S-curve scoliosis
– Idiopathic
– Congenital
– Syndromic
○ C-curve scoliosis
– Neuromuscular
– Neurofibromatosis
– Scheuermann disease
– Congenital
– Syndromic
○ Short-curve scoliosis
– Tumor
– Trauma
– Infection
– Radiation
– Congenital
– Neuropathic
Radiographic Findings
• Radiography
○ Standing PA radiograph of full thoracic and lumbar spine
on single cassette (14" x 36")
– PA projection gives lower radiation dose to breasts
than AP
– Lifts used to equalize limb lengths if needed
○ Method of Cobb is standard for measuring scoliosis
– Draw lines parallel to endplates of terminal vertebrae
– If endplates difficult to see, use pedicles as landmarks
Disorders of Alignment
– Cobb angle is between terminal endplates
– Can also measure angle between 2 lines drawn
perpendicular to endplates
– 2nd method is easier with small curves
○ Choosing correct vertebrae to measure scoliosis is critical
to accuracy and monitoring
– Terminal vertebra is one with greatest angle of
endplate from horizontal
– Rotoscoliosis: Terminal vertebra spinous process
returns to midline
– Interobserver variability 7-10°
○ Coned-down radiographs for better definition of
vertebral abnormalities and pedicles
○ Lateral radiograph to show sagittal plane abnormalities
– Usually alters normal thoracic kyphosis, lumbar
lordosis
○ Estimate rotational deformity by rib displacement on
lateral radiograph
CT Findings
• Bone CT
○ Shows congenital bone anomalies, tumor, infection,
postoperative complications
○ Not as useful for measuring curves compared with
radiography
MR Findings
• Shows bone and spinal cord anomalies, syrinx, tumor,
infection
Imaging Recommendations
• Best imaging tool
○ Radiography for initial diagnosis
• Protocol advice
○ Multiplanar MR to screen for bone, cord abnormalities
– Coronal and sagittal T1WI and T2WI
– Include craniocervical junction
– Axial T2WI through areas of suspected abnormality
– Axial T2WI through conus
○ CT for surgical planning
– 1- to 3-mm multidetector CT with reformatted images
– 3D helpful
○ CT for surgical complications
– Thin, overlapping sections minimize artifact
– Bone and soft tissue windows
DIFFERENTIAL DIAGNOSIS
Idiopathic Scoliosis
• Classic S-curve scoliosis
Neuromuscular Scoliosis
• Usually long sweeping curvature
• Neurologic disorders
• Muscular dystrophies
Congenital Scoliosis
• Morphology of curve highly variable
○ Focal short curves common
• Due to abnormal vertebral formation and segmentation
143
Scoliosis
Scoliosis Due to Congenital Syndromes Without
Vertebral Anomalies
• Often complex curvatures
• Neurofibromatosis
• Marfan
• Osteogenesis imperfecta
• Diastrophic dwarfism
• Ehlers-Danlos syndrome
Disorders of Alignment
Scoliosis Due to Infection
• Usually short curve
• Painful
• Systemic signs may be absent
• Pyogenic bacteria, tuberculosis, fungi
Scheuermann Disease
• 15% have scoliosis as well as kyphosis
• Scoliosis usually mild compared to kyphosis
Scoliosis Due to Tumor
• Short curve
• Painful
• Tumor may be occult on radiography
• Multiplanar MR most helpful for evaluation
Scoliosis Due to Trauma
• Usually see posttraumatic deformity
• Stress fracture may be occult cause
Scoliosis Due to Radiation
• Usually avoided today by radiation port placement
• Radiation to entire vertebra rather than portion preferred
Degenerative Scoliosis
• Develops in adults
• Degenerative disc disease, facet arthropathy seen
• Can also have secondary degenerative disease from
idiopathic scoliosis
Neuropathic Spine
• Rapidly developing spine deformity
• Bony destruction seen on radiography
Compensatory Scoliosis
• Due to limb length inequality
• Can be diagnosed on frontal spine radiographs by position
of iliac crests
Positional Scoliosis
• Poor positioning by radiology technologist
• Present on supine radiographs
• Resolves on upright radiographs
Iatrogenic Scoliosis
• Rib resection
• Level above lumbar fusion
• Hardware failure
PATHOLOGY
General Features
• Etiology
○ Variable, causes listed above
• Epidemiology
○ Common
Gross Pathologic & Surgical Features
• Deformity of trunk visible on physical examination
Staging, Grading, or Classification Criteria
• Etiology
• Direction of curve
• Severity of curve
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Visible truncal deformity
○ Idiopathic scoliosis asymptomatic
○ Painful scoliosis indicates underlying abnormality
Demographics
• Age
○ Usually presents in childhood or adolescence
• Gender
○ Idiopathic M:F = 1:7
Natural History & Prognosis
• Most scoliosis is mild
• May progress rapidly, especially during growth spurts
• Degenerative disc disease common
○ Greatest along concave aspect of scoliosis
• Severe scoliosis
○ Respiratory compromise
○ Neurologic symptoms
○ Instability
Treatment
• Options, risks, complications
○ Observation for minor curves
○ Bracing for curves > 25°
○ Fusion for rapidly progressive curves, curves > 40°
DIAGNOSTIC CHECKLIST
Consider
• Short-curve scoliosis usually has underlying abnormalities
SELECTED REFERENCES
1. Parnell SE et al: Vertical expandable prosthetic titanium rib (VEPTR): a review
of indications, normal radiographic appearance and complications. Pediatr
Radiol. 45(4):606-16, 2015
2. Ahmed R et al: Long-term incidence and risk factors for development of
spinal deformity following resection of pediatric intramedullary spinal cord
tumors. J Neurosurg Pediatr. 13(6):613-21, 2014
3. Harris JA et al: A comprehensive review of thoracic deformity parameters in
scoliosis. Eur Spine J. 23(12):2594-602, 2014
4. Karami M et al: Evaluation of coronal shift as an indicator of neuroaxial
abnormalities in adolescent idiopathic scoliosis: a prospective study.
Scoliosis. 9:9, 2014
5. Presciutti SM et al: Management decisions for adolescent idiopathic scoliosis
significantly affect patient radiation exposure. Spine J. 14(9):1984-90, 2014
6. Waldt S et al: Measurements and classifications in spine imaging. Semin
Musculoskelet Radiol. 18(3):219-27, 2014
7. Arlet V et al: Congenital scoliosis. Eur Spine J. 12(5):456-63, 2003
144
Scoliosis
Disorders of Alignment
(Left) Coronal bone CT reveals
multiple examples of vertebral
segmentation failure. Several
right-sided hemivertebra ſt
have failed to successfully
segment from the adjacent
vertebra, producing a jumble
of malformed vertebra and
multiple-curve scoliosis.
(Right) Frontal bone CT 3D
surface rendering of
congenital scoliosis, secondary
to multiple vertebral
anomalies (same patient), is
helpful for fully characterizing
contribution of the various
anomalous vertebra to
scoliosis and kyphosis to
facilitate treatment planning.
(Left) Coronal 3D reformatted
bone CT reveals a right L3
hemivertebra ſt resulting in
convex right congenital
scoliosis. There are
rudimentary left L3 pedicle
and posterior elements st.
(Right) PA radiograph of the
thoracolumbar spine
demonstrates a long sweeping
curvature neuromuscular
dextroscoliosis in a cerebral
palsy patient. The intrathecal
baclofen infusion pump ſt
and gastrostomy tube are
clues to the diagnosis.
(Left) Anteroposterior
radiograph depicts focal high
cervical short-curve scoliosis in
a patient with
neurofibromatosis type 1.
Vascular clips in the right neck
reflect the surgical site of prior
neurofibroma resection.
(Right) Anteroposterior
radiograph demonstrates a
large posterior paraspinal
mass ſt causing shortsegment, tumor-related
scoliosis. Note osseous
remodeling of the ipsilateral
ribs.
145
Kyphosis
KEY FACTS
TERMINOLOGY
• Accentuated thoracic ± reduced normal cervical, lumbar
lordotic spinal curvature
• Normal 20-40°, hyperkyphotic if > 40°
• Curvature secondary to vertebral anomalies, degenerative
spine disease, or idiopathic causes
IMAGING
Disorders of Alignment
• Accentuated dorsal thoracic curvature on lateral image
• Look for vertebral anomalies in patient with scoliosis or
kyphosis
• Common in thoracic spine but can occur at any spinal level
TOP DIFFERENTIAL DIAGNOSES
• Scheuermann kyphosis
○ Wedging of 3 or more vertebral bodies, undulation of
endplates
• Idiopathic kyphosis
○ Vertebral anomalies absent
(Left) Lateral radiograph
demonstrates smoothly curved
thoracic kyphosis with
premature upper thoracic
degenerative disc disease ſt
in this patient with
degenerative kyphosis. (Right)
Lateral chest radiograph
(idiopathic kyphosis) reveals
diffuse upper thoracic
kyphosis with a round-back
deformity. There is no
underlying cause of kyphosis
(e.g., Scheuermann disease,
prior trauma, congenital
anomaly, or infection).
• Kyphosis or scoliosis due to syndromes
○ Neurofibromatosis type 1
○ Marfan syndrome
○ Osteogenesis imperfecta
• Traumatic kyphosis
• Osteomyelitis, granulomatous
PATHOLOGY
• May be congenital or acquired
• Congenital abnormalities due either to failure of
development &/or failure of segmentation
CLINICAL ISSUES
• May be isolated anomaly or associated with multisystem
anomalies (VACTERL)
DIAGNOSTIC CHECKLIST
• Image entire spine (particularly in children) to exclude
additional bone or cord abnormalities, Chiari 1
malformation
146
(Left) Lateral radiograph
(repaired high
myelomeningocele, congenital
vertebral segmentation failure
with kyphosis) depicts severe
focal lumbosacral kyphotic
curvature. There is also
posterior spinal dysraphism
and segmentation failure of
the lumbar and sacral vertebra
associated with kyphosis.
(Right) Sagittal T2WI MR
(same patient) reveals distal
spinal cord attenuation at the
thoracolumbar junction
myelomeningocele repair site.
Note extensive congenital
vertebral anomalies.
Kyphosis
TERMINOLOGY
Definitions
• Accentuated thoracic ± reduced normal cervical, lumbar
lordotic spinal curvature
○ Spinal curvature secondary to vertebral anomalies,
degenerative spine disease, or idiopathic causes
IMAGING
General Features
• Best diagnostic clue
○ Accentuated dorsal thoracic spine curvature on lateral
image
○ Vertebral anomaly in patient with scoliosis or kyphosis
• Location
○ Most common in thoracic spine but can occur at any
spinal level
Radiographic Findings
• Accentuated dorsal curvature of thoracic spine &/or
reduced lordotic curvature of cervical, lumbar spine
CT Findings
• Improved visualization of anomalous vertebrae compared
with radiographs
• Coronal and sagittal reformatted images essential
○ Helps confirm abnormal curvature and better
demonstrates osseous abnormalities in osteopenic
patients
○ 3D imaging helpful for surgical planning
MR Findings
• Similar to CT but better demonstrates spinal cord, soft
tissues
Imaging Recommendations
• Best imaging tool
○ CT preferable for surgical planning in adults because of
superior spatial resolution
○ Multiplanar MR best modality to evaluate full spine in
children
DIFFERENTIAL DIAGNOSIS
Scheuermann Kyphosis
• Wedging of 3 or more vertebral bodies, undulation of
endplates
• 15% have scoliosis as well as kyphosis
Idiopathic Kyphosis
• Vertebral anomalies absent
Kyphosis or Scoliosis Due to Syndromes
• Neurofibromatosis type 1
• Marfan syndrome
• Osteogenesis imperfecta
• Diastrophic dwarfism
• Ehlers-Danlos syndrome
Traumatic Kyphosis
• Short -curve kyphosis, vertebral body deformity
Disorders of Alignment
Osteomyelitis, Granulomatous
• Paraspinous cold abscess, endplate destruction
• Kyphosis may be severe (gibbus) deformity
PATHOLOGY
General Features
• Genetics
○ Sometimes associated with chromosomal abnormalities
• Associated abnormalities
○ Spinal cord abnormalities
– Syringohydromyelia
– Diastematomyelia
– Tethered cord
○ Caudal regression
○ Component of VACTERL association
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Visible spinal axis deformity
• Clinical profile
○ May be isolated anomaly or associated with multisystem
anomalies (VACTERL)
Demographics
• Age
○ Congenital kyphosis present at birth but may not be
evident clinically until later in childhood or adolescence
○ Acquired kyphosis usually adolescence to adulthood
• Gender
○ M = F
• Epidemiology
○ Sporadic, relatively uncommon
Natural History & Prognosis
• Congenital kyphosis
○ Kyphosis tends to progress without treatment; fusion
during childhood indicated
• Degenerative kyphosis frequently progressive
• Scheuermann kyphosis frequently progressive
Treatment
• Brace is of limited utility
• Fusion of congenital kyphosis to prevent paralysis
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Lateral radiography usually adequate to measure curvature
○ CT may be necessary in osteopenic patients
• Image entire spine to exclude additional bone or cord
abnormalities, Chiari 1 malformation in children especially
SELECTED REFERENCES
1. Ansari SF et al: Dorsal midline hemivertebra at the lumbosacral junction:
report of 2 cases. J Neurosurg Spine. 22(1):84-9, 2015
2. Cho W et al: The prevalence of abnormal preoperative neurological
examination in Scheuermann kyphosis: correlation with X-ray, magnetic
resonance imaging, and surgical outcome. Spine (Phila Pa 1976).
39(21):1771-6, 2014
147
Degenerative Scoliosis
KEY FACTS
TERMINOLOGY
• Lateral curvature in spine due to degenerative disc and
facet disease in older patients
• Deformity in skeletally mature patient with Cobb angle of >
10° in coronal plane
• Predominance of lower lumbar curves
IMAGING
Disorders of Alignment
• Conventional standing full-length PA and lateral
radiographs for monitoring curve progression
• Most common from L1 to L4
○ Lateral listhesis, vertebral rotation
○ Disc space loss, endplate sclerosis
○ Circumferential endplate spurring
○ Facet arthropathy
○ Spondylolisthesis, loss of lordosis
TOP DIFFERENTIAL DIAGNOSES
• Adult idiopathic scoliosis
(Left) Anteroposterior
radiography shows lumbar
rotatory levoscoliosis with
associated multilevel marked
disc height loss and endplate
sclerosis. There is left lateral
listhesis of L4 on L5. (Right)
Lateral radiography shows
loss of lumbar lordosis with
multilevel disc space height
loss and degenerative
endplate bony eburnation,
worst at L2-L3 ſt.
• Neuromuscular
• Congenital scoliosis
• Posttraumatic, inflammatory, or neoplastic
• Dysplasias (neurofibromatosis type 1, Marfan)
PATHOLOGY
• Asymmetric degenerative change at multiple levels
○ Asymmetric loading of spinal segments gives 3-
dimensional deformity
○ Spondylolisthesis &/or rotatory listhesis
CLINICAL ISSUES
• Low back pain, radiculopathy
○ Pain worse with prolonged spinal extension
○ Radiculopathy not reliably relieved by flexion
• Risk factors for curve progression
○ Cobb angle > 30°
○ Lateral listhesis > 6 mm
○ > 30° apical vertebral rotation
148
(Left) Coronal reformation of
nonenhanced lumbar spine CT
shows mild levoscoliosis at L4L5 with vacuum disc
phenomenon and right-sided
endplate sclerosis. There is
disc height loss at L3-L4 and
L4-L5. (Right) Sagittal T1WI
MR shows grade 1
anterolisthesis of L4 on L5
with severe disc degeneration
and vacuum phenomenon.
Degenerative disc and
endplate disease is also
present at L2-L3 and L5-S1.
There is severe central
stenosis at L4-L5 and L5-S1.
Scoliosis Instrumentation
KEY FACTS
Disorders of Alignment
TERMINOLOGY
• Spinal fusion surgery recommended when curve
magnitude > 40-45° for adolescent idiopathic scoliosis
• Adult scoliosis presents with lumbar back, ± leg pain, L3–L4
rotatory subluxation, L4–L5 tilt, and L5–S1 disc
degeneration on radiographs
IMAGING
• Radiographs
○ Main thoracic, thoracolumbar, and lumbar curves should
be assessed for structural characteristics
○ 36" standing AP and lateral radiographs and supine side-
bending radiographs
○ In adult scoliosis, assess for degenerated changes and
rotatory ± lateral listhesis
• CT
○ Assess integrity of instrumentation
○ Look for osseous bridging at levels of interbody fusion
and lucency along screw tracks
• MR
○ Preoperative planning to evaluate for central &/or
foraminal stenosis and disc degeneration
CLINICAL ISSUES
• Adult bones tend to be weaker or osteoporotic, making
instrumentation and fusion more difficult
• Degenerative disc changes, spinal stenosis, and facet
arthropathy can be exacerbated and in turn exacerbate
scoliosis, leading to more rigid spines
• Goals: Prevent progression, restore acceptability of clinical
deformity, reduce curvature
○ Resolve pain ± make it more controllable with
medications
○ Fuse spine in as normal anatomical position as possible
○ Since degenerated lumbar curves present with loss of
lordosis, surgical plan should specifically address this
issue
Anteroposterior radiograph shows sigmoid scoliosis of the
thoracic and lumbar spines st. Fusion is extended to L5 if
there is fixed tilt or subluxation at L4–L5, or to the sacrum
if L5-S1 central or foraminal decompression is needed.
AP radiograph depicts posterior fusion from the
thoracolumbar junction st to sacrum. Extension of fusion
to the sacrum increases the incidence of pseudarthrosis
and reoperation. Instrumentation into iliac protects L5S1 construct and decreases pseudoarthrosis.
149