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134 Spine Core Knowledge in Orthopaedics
Post-traumatic Kyphosis
●
As noted previously, trauma can lead to kyphosis acutely or
subacutely. Initial, deformity is largely based on the injury
pattern. Later deformities are generally seen only if
treatment is inadequate in providing stability during healing.
●
Fractures with significant comminution of the anterior
spinal column or disruption of the posterior column are
most likely to progress to kyphosis (flexion compression
and flexion distraction injuries are particularly prone to
such deformities).
●
The kyphotic deformity is best measured by comparing
the superior and inferior endplates of the vertebrae
directly above and below the fractured segment,
respectively (Kuklo et al. 2001).
●
Indications for surgical intervention include the
following (Vaccaro et al. 2001):
●
Progression of kyphotic deformity
●
New or progressive neurologic deficit
●
Localized kyphotic deformity of greater than 30 degrees
●
Unacceptable cosmetic appearance with a rigid
deformity
●
Goals of surgery are neural decompression, spinal
reconstruction, and stabilization to restore lumbar lordosis
(Fig. 10–8).
Figure 10–8: A 31-year-old woman. She sustained a T12
burst fracture (A) with splaying of the posterior elements (B).
She underwent a T12 corpectomy with an expandable cage
and anterior rod fixation.
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 135
●
In the setting of a chronic lumbar deformity, SmithPeterson or pedicle subtraction osteotomies are
alternatives to combined anterior and posterior
reconstruction procedures.
Degenerative Kyphosis
●
As with the cervical spine, the lumbar spine is prone to
spondylosis.
●
As degenerative changes progress, lumbar kyphosis or
scoliosis may develop.
●
Conservative treatment is the mainstay of treatment for
such conditions.
●
If conservative treatment fails and the lumbar deformity
is progressive, surgical intervention may be considered.
●
In addition to the anterior and posterior surgical options
described for other regions of the spine, transforaminal
lumbar interbody fusion and posterior lumbar interbody
fusion are additional posterior surgical alternatives for
focal deformities in this region of the spine.
●
The method of surgical correction must be tailored to
the patients’ symptoms and underlying pathology.
References
Albert TJ,Vaccaro A. (1998) Postlaminectomy kyphosis. Spine 23:
2738-2745.
Review of risk factors, biomechanics, workup, and surgical
treatment of postlaminectomy kyphosis.This review promotes
understanding of biomechanical principles to prevent and
surgically treat postlaminectomy kyphosis.
Al-Sebai MW, Al-Khawashki H,Al-Arabi K et al. (2001) Operative
treatment of progressive deformity in spinal tuberculosis. Int
Orthop 25(5): 322-325.
Report on 14 patients with spinal tuberculosis treated surgically.
All had progressive kyphotic deformity.The report states that
anterior and posterior debridement with fusion and
instrumentation can improve correction in deformity in patients
with progressive deformity, disease of three or more vertebrae,
or destruction of anterior and posterior columns.
Bradford DS. (1977) Juvenile kyphosis. Clin Orthop 128: 45.
Review of SD as a cause of juvenile kyphosis.The article
describes the use of bracing for successful therapy. Surgery may
be necessary with severe kyphosis, pain, neurologic compromise,
or a combination of these.
Canale ST. (1998) Scheuermann’s disease. In: Campbell’s Operative
Orthopaedics, 9th edition. St. Louis: Mosby, pp. 2942-2947.
This chapter provides a detailed review of literature and modern
approaches to treatment and surgical intervention in SD. It
provides an overview of etiology and comprehensive review of
diagnosis and treatment.The chapter also provides a range of
lumbar lordosis and thoracic kyphosis.
Dai LY. (2002) Low lumbar spinal fractures: Management options.
Injury 33(7): 579-582.
Retrospective review of 54 patients with low lumbar spinal
fractures.The article reviews the management options for low
lumbar fractures, stating that most compression fractures can be
managed conservatively. Denis classification of lumbar fractures
was drawn from this article.
Garfin SR,Yuan HA, Reiley MA. (2001) New technologies in
spine: Kyphoplasty and vertebroplasty for the treatment of
painful osteoporotic compression fractures. Spine 26(14):
1511-1515.
Literature review providing useful facts and the results of the
use of vertebroplasty and kyphoplasty in the treatment of
osteoporotic compression fractures.
Harrison DD, Janik TJ,Troyanovich SJ et al. (1996) Comparison of
lordotic cervical spine curvatures to a theoretical ideal model of the
static sagittal cervical spine. Spine 21(6): 667-675.
This article is useful in providing an average measurement of
cervical lordosis.
Kornblum M, Stanitski DF. (1999) Disorders of the pediatric and
adolescent spine: Spinal manifestations of skeletal dysplasias. Orthop
Clin N Am 30(3): 501-520.
This article provides a comprehensive review of different
etiologies in spinal deformity caused by skeletal dysplasias.
Pertinent information is provided in specific cases of skeletal
dysplasias that cause eventual spinal kyphosis, such as in
achondroplasia and diastrophic dysplasia.
Kuklo TR, Polly DW, Owens BD et al. (2001) Measurement of
thoracic and lumbar fracture kyphosis: Evaluation of intraobserver,
interobserver, and technique variability. Spine 26(1): 61-65.
Statistical analysis of various measurement techniques for
thoracolumbar burst fracture kyphosis on lateral radiographs to
determine the most reliable measurement technique. Fifty lateral
radiographs were studied and reviewed by three spine surgeons.
Of the five methods used, measuring from the superior endplate
of the vertebral body one level above the injured vertebral body
to the inferior endplate of the vertebral body one level below
showed the best interobserver and intraobserver reliability
overall.
Matsunaga S, Sakou T, Nakanisi K. (1999) Analysis of the cervical
spine alignment following laminaplasty and laminectomy. Spinal
Cord 37: 20-24.
Comparative retrospective study involving patients who had
undergone either laminaplasty or laminectomy to assess the
incidence of the buckling-type alignment that follows these
procedures.The purpose was to know the mechanical changes in
the alignment of the cervical spine in these patients. Results
favor laminaplasty over laminectomy from the aspect of
mechanics.
Moore KL, Dalley AF. (1999) Curvatures of the vertebral column.
In: Clinically Oriented Anatomy, 4th edition, pp. 434-435.
Philadelphia: Lippincott Williams and Wilkins.
This section includes embryologically relevant information
about the development of the different spinal curvatures. It
provides useful information for anatomic background.
Stagnara P, Mauroy JC, Dran G et al. (1982) Reciprocal angulation
of vertebral bodies in a sagittal plane: Approach to references for
the evaluation of kyphosis and lordosis. Spine 7: 335-412.
This article is useful in providing an average measurement of
thoracic kyphosis.
136 Spine Core Knowledge in Orthopaedics
Vaccaro AR, Silber JS. (2001) Post-traumatic spinal deformity. Spine
26(24S): 5111-5118.
Review article that provides useful information about the
etiology, diagnosis, and treatment of cervical, thoracic, and
lumbar post-traumatic deformity. The article focuses on the
importance of reestablishing integrity of compromised spinal
columns so that spinal stability can be restored when
considering surgical management.
Weinstein JN, McLain RJ. (1987) Primary tumors of the spine.
Spine 12: 843-851.
Review of 82 cases of primary neoplasms of the spine in an
attempt to identify common diagnostic and prognostic features.
The series justifies an aggressive surgical approach in the
treatment of spinal tumors with prolonged survival.
Wimmer C, Ogon M, Sterzinger W et al. (1997) Conservative
treatment of tuberculous spondylitis:A long-term follow-up study. J
Spinal Disorders 10(5): 417-419.
Retrospective follow-up study of 40 tuberculosis patients
treating spondylitis with orthotic supports for an average of 16
months and with antituberculous agents. Conservative treatment
is proposed as an alternative to surgical intervention in kyphotic
angles of less than 35 degrees.
CHAPTER
11
Spinal Scoliotic Deformities
Adolescent Idiopathic, Adult Degenerative,
and Neuromuscular
Daniel J. Sucato
M.D., M.S.,Assistant Professor, Department of Orthopaedics, University of Texas
at Southwestern; and Staff Orthopaedist,Texas Scottish Rite Hospital for Children, Dallas,TX
Adolescent Idiopathic Scoliosis
Anatomy and Pathophysiology
●
The etiology of adolescent idiopathic scoliosis (AIS) has
not been elucidated; however, several theories have been
studied and developed.
Genetics
●
A familial predisposition has been accepted.
●
Studies of monozygous twins demonstrate a concordance
rate of 73%.
●
The mode of inheritance is debated.
Effect of Connective Tissue
●
Collagen and elastic fibers are the principal elements
supporting the spine.
●
An abnormal collagen/proteoglycan ratio of the
intervertebral disks has been demonstrated.
●
Elastic fiber abnormalities have been demonstrated in
patients with AIS.
●
A decrease has been seen in type II (fast twitch) fibers in
the paraspinous muscles.
●
Others have demonstrated normal fibers on the
convexity but low frequency of type I (slow twitch)
fibers on the concavity.
●
A decrease has been found in the muscle spindles of the
paraspinous muscles.
Muscle Contractile Mechanisms
●
The contractile systems (actin and myosin) of platelets
and muscle are similar and are partially regulated by
calmodulin.This has been studied in AIS patients.
●
Platelet calmodulin levels are higher in progressive curves.
●
Melatonin (the antagonist of calmodulin) is lower in
progressive curves.
●
Contractile mechanisms have been studied in
pinealectomized rats (produces decreased melatonin levels).
Neurology
●
Inconsistent data
●
Impaired peripheral, visual, and spatial proprioception
Role of Growth and Development
●
Hypokyphosis has been seen in AIS. It may be a result of
imbalance of anterior and posterior growth.
●
Some authors have found patients with scoliosis to be
taller with less kyphosis.
137
138 Spine Core Knowledge in Orthopaedics
●
Accelerated spinal growth starts earlier when compared
with controls.
Diagnostic Tools
History
Other Examination
●
Lower extremities
●
Ensure no asymmetry in leg circumference, size, or length
●
Look for asymmetric foot deformities (intracanal
pathology)
Pain
●
Occurs in 30% of patients with AIS
●
Uncharacteristic pain (awakens from sleep, continuous,
radiating, or severe)—unusual and requires further study
Age at Onset
●
Patients may present symptoms in the adolescent period;
however, they may have had earlier onset. It is important
to determine the etiology—it may be juvenile or
infantile onset.
Growth Potential
●
Age—Girls peak growth occurs from 11 to 12 years; boys
peak from 13 to 14 years.
●
Menarcheal status—Premenarcheal girls are a greater risk
for progression and may crankshaft following posterioronly surgery.
Family History
●
It is important to determine sibling occurrence to allow
evaluation.
Physical Examination
Assessment of Deformity
●
Standing examination
●
Coronal imbalance assessment
●
Coronal curve assessment
●
Shoulder height or asymmetry
●
Adams forward bend test
●
Patient bends at the waist until the trunk is at 90 degrees
●
Rotational deformity assessment of the upper
thoracic, thoracic, and thoracolumbar or lumbar curves
●
Assessment for symmetry of movement with flexion
(absence of list to one side may denote nonidiopathic
scoliosis)
Radiographic Examination
Posteroanterior–Anterior Standing
●
Measure upper thoracic, thoracic, and thoracolumbar or
lumbar curves (Cobb method)
●
Determine the deviation of C7 plumb line from the
center–sacral–vertical line (CSVL)
●
Trunk shift—Deviation of the mid-distance of the rib
margins to CSVL
●
Risser stage—See Fig. 11–1
●
Status of triradiate cartilage (acetabular physis)—Open or
closed
Neurologic Examination
●
Motor and sensory examination—Usually intact even
with intracanal pathology
●
Deep tendon reflexes—Knees and ankles
●
Abdominal reflexes
●
A lateral-to-medial gentle stroke of the abdomen,
which elicits movement of the umbilicus
●
Should be symmetric (absent or present)
●
If asymmetric, then high correlation with neural axis
pathology (syringomyelia, tethored cord)—obtain
magnetic resonance imaging (MRI)
Figure 11–1: Risser stages to determine skeletal maturity.
Risser 0 = No ossification of the iliac apophysis. Risser 1-4 =
Ossification beginning laterally and finishing medially when
the iliac wing is divided into four sections. Risser 5 = Fusion
of the ossified iliac apophysis to the ilium.
Lateral Radiograph
●
Thoracic kyphosis and lumbar lordosis (Cobb method)
●
Junctional kyphosis
●
Between the structural upper thoracic and middle
thoracic curves
●
Between the structural middle thoracic and the
thoracolumbar or lumbar curves
●
Sagittal balance—C7 plumb normally falls at the
posterior edge of L5-S1
●
Presence of thoracic hypokyphosis or apical lordosis is
normal in AIS; absence may indicate neural axis
pathology
Bend Films
Purpose
●
Determine the curve type—more than 25 is structural
(Lenke et al. 2001)
●
Determine the flexibility index for each curve:
●
Subtract the bend Cobb angle from the
posteroanterior–anterior (PA) Cobb angle and divide
by PA Cobb × 100
●
Determine fusion levels in the lumbar spine:
●
Flexibility of the disk below the distal fusion vertebra,
which helps determine the distal extent of fusion
●
Ability of the planned distal fusion level to center over
the sacrum
CHAPTER 11
Spinal Scoliotic Deformities 139
Types of Bend Films
●
Supine anteroposterior best-effort bend
●
Patient lies supine on a table and bends to the right
and the left
●
Most commonly used
●
Push-prone test—Patient is prone and the examiner
pushes medially and anteriorly on the rotational
prominence
●
Fulcrum bend film
●
Patient lies in a lateral position with the apex of curve
on a large roll
●
May be better for the assessment of thoracic curve
flexibility
●
Traction films
●
Supine patient has manual traction applied (more
common)
●
Standing patient has halter traction applied
Magnetic Resonance Imaging
(Fig. 11–2)
●
Absolute indications
●
Neurologic abnormalities
●
Juvenile and infantile onset
●
Congenital vertebral abnormalities
●
Cutaneous manifestations of dysraphism
Figure 11–2: Magnetic resonance image of the cervical spine
in a patient with a left thoracic curve. Note the large cervical
syrinx.
●
Relative indications
●
Atypical curve pattern, i.e., left thoracic curve or
thoracic kyphosis
●
Rapidly progressing curve
●
Painful scoliosis—Often difficult to sort out the pain
Bone Scan
●
Indications
●
Painful scoliosis without known etiology
Natural History
●
The prevalence of AIS is 2% in the normal population
with curves greater than 10 degrees. Of these patients,
5% will demonstrate progression greater than 30
degrees.
Gender Distribution
●
Small curves—Girls equal boys
●
Larger curves—8 times more common in girls than in
boys
140 Spine Core Knowledge in Orthopaedics
Risk Factors for Progression
●
Skeletal immaturity (open triradiate cartilage, Risser sign
0-1, and premenarcheal)
●
Curve location—Thoracic curves progress less often than
lumbar curves
●
Curve magnitude
●
Larger curves progress more often than smaller ones
●
At maturity, thoracic curves greater than 50 degrees
progress into adulthood (average one per year)
(Table 11–1)
●
Thoracolumbar/lumbar curves greater than 40 degrees
progress into adulthood (especially with coronal
decompensation)
Curve Classification
●
Based on the apex of the curve
●
Cervical—Apex between C1 and C6
●
Cervicothoracic—Apex between C7 and T1
●
Thoracic—Apex between T2 and the T11-T12 disk
space
●
Thoracolumbar—Apex between T12 and L1
●
Lumbar—Apex between the L1-L2 disk space and L4
Table 11–1: Curve Progression Risk*
CURVE MAGNITUDE CURVE MAGNITUDE
(10-19 DEGREES) (20-29 DEGREES)
Risser sign 0-1 22% 68%
Risser sign 2-4 1.6% 23%
*
(Lonstein JE et al.1984.)
●
Lumbosacral—Apex between L4 and S1
●
King classification—Traditional classification of thoracic
curves
●
King I—Lumbar curve greater than the thoracic curve
●
King II—Thoracic curve with a compensatory lumbar
curve that crosses the midline
●
King III—Thoracic curve with a lumbar curve that
does not cross the midline
●
King IV—Long thoracic curve in which L4 is tilted
into the curve
●
King V—Double thoracic curve
●
Lenke et al. (2001) classification—A more comprehensive
and newer classification (Fig. 11–3)
Figure 11–3: Lenke et al. (2001) curve classification. The three-part classification consists of curve type, lumbar modifier, and
thoracic sagittal profile.
●
Reliability has been tested with varying results
●
Three components of the spine analyzed to produce
the classification
Six Curve Types
●
The larger curve is always considered structural; smaller
curves are structural if the patient fails to bend to less
than 25 degrees.
●
1—Single thoracic
●
2—Double thoracic
●
3—Double major
●
4—Triple major
●
5—Lumbar curve without thoracic curve
●
6—Lumbar curve with compensatory thoracic curve
Lumbar Modifier
●
Based on where the CSVL falls in relation to the apical
lumbar vertebra
●
A—CSVL falls between the pedicles
●
B—CSVL falls on the pedicle or lateral to the pedicle
within the vertebral body
●
C—CSVL falls outside of the vertebral body
Thoracic Kyphosis Modifier
●
Measured from T5 to T12
●
“−”—Kyphosis less than 10
●
“N”—Kyphosis between 10 and 40
●
“+”—Kyphosis greater than 40
Nonoperative Treatment
Observation
●
Most patients who have AIS do not progress to the point
of treatment.
●
Radiographs should be performed every 4-6 months
depending on the risk of progression.
●
PA radiographs are used to determine the curve
magnitude (Cobb method).
CHAPTER 11
Spinal Scoliotic Deformities 141
Goal of Bracing
●
Maintain the present curve magnitude or prevent it
from progressing to a level that means surgery is
required
Effectiveness
●
Still questioned today despite many studies (limited by
the ability to measure compliance)
●
SRS 1995 publication: Braced versus nonbraced
patients—Progression was seen in 64% of nonbraced
patients compared with 26% of braced patients
●
Unpublished data from Texas Scottish Rite Hospital by
Katz et al.
●
Measured compliance with heat sensor
●
Preliminary results demonstrate the dose response
to bracing; more than 12 hours in a brace was
more effective in the skeletally immature
patients
Operative Treatment
Indications
●
Thoracic curves
●
Immature patients—Curve magnitude greater than
40-50 degrees
●
Mature patients—Curve magnitude greater than 50
degrees
●
Thoracolumbar/lumbar curves
●
Curve magnitude greater than 40 degrees with
significant coronal decompensation
Goals of Operative Treatment
●
Halt curve progression with fusion
●
Curve and deformity correction using instrumentation
Fusion Techniques
●
Complete facetectomies at all instrumented levels
Bracing (Table 11–2)
Indications
●
Curve progression to 25-30 degrees but less than 45 degrees
●
Potential for growth (Risser sign less than 4)
Bone Graft
●
Autologous iliac crest
●
Most commonly used
●
Relatively high morbidity because of pain
●
Rib—From concomitant thoracoplasty
Table 11–2: Types of Braces for Adolescent Idiopathic Scoliosis
TYPE OF BRACE INDICATIONS WEAR SCHEDULE COMPLIANCE
TLSO (Boston overlap)* All curve types 16-22 hours Middle compliance
Bending brace (Charleston) Thoracolumbar, lumbar curves 8-10 nighttime hours Best compliance
(25-35 degrees)
Thoracic curves with apex above T7 16-22 hours Least compliance
CTLSO (Milwaukee)
*
TLSO,
Thoracolumbosacral orthosis.
§
CTLSO,
Cervical thoracolumbosacral orthosis.
§
142 Spine Core Knowledge in Orthopaedics
●
Allograft—Fusion rates similar to autologous
●
Local only—Rare
Fixation
●
Modern segmental spinal instrumentation uses multiple
fixation points and dual rods posteriorly and single or
dual rods anteriorly.
Hooks
●
Pedicle
●
Up-going hooks under the lamina or inferior facet
engaging the pedicle
●
Can be placed in thoracic spine to T10
●
Sublaminar—Can be up-going or down-going
●
Transverse process—can be placed as up-going or downgoing weakest hook
●
Wires
●
Sublaminar—Excellent for translation (laterally and
posteriorly)
●
Through the spinous process:Wisconsin (Drummond)
wires
●
Pedicle screws
●
Provide optimal fixation of all three columns
●
Generally used in the lower thoracic and the lumbar
spine
●
Becoming used more often in the thoracic spine
●
Anterior structural support
●
Mesh cages or ring allografts
●
Provides improved structural stiffness when
performing anterior instrumentation and fusion
Posterior Correction Maneuvers
●
All correction maneuvers attempt to translate the spine
posteriorly and laterally and to derotate the spine in the
axial plane
●
Rod rotation
●
Popularized by Dubousset
●
Rod contouring and placement on the concavity are
followed by a counterclockwise rotation (for a right
thoracic curve)
●
Translation or cantilever—Distal attachment of a
contoured rod and then translation of the spine to
the rod
●
In situ contouring—The rod is attached to the contour
of the spine and then shaped to improve spinal
deformity
Figure 11–4: Preoperative and
postoperative radiographs following
anterior fusion from T9 to L2 using a
single 0.25-inch rod and anterior
structural support at the T12-L1 and
L1-L2 levels for a 53 degree curve.
Restoration of coronal and sagittal
balance is achieved.
CHAPTER 11
Spinal Scoliotic Deformities 143
Anterior Correction Maneuvers
●
Rod rotation (usually for thoracolumbar or lumbar
curves)
●
The rod is contoured to the convexity of the spine,
and rod rotation is performed to improve the coronal
plane and restore or maintain lumbar lordosis.
●
Compression (usually for thoracic curves)
●
The rod is seated completely or more often distally
initially or proximally initially followed by
compression.
●
A cantilever maneuver can be used (for the partially
seated rod) followed by compression at each level.
Treatment Options
Anterior Instrumentation and Fusion
(Fig. 11–4)
●
Most common method used to treat thoracolumbar or
lumbar curves
●
Single thoracic curves can be treated either through an
open thoracotomy or thoracoscopically (Fig. 11–5)
Fusion Levels
●
Nearly always proximal end vertebra to distal end
vertebra
Posterior Instrumentation and Fusion
(Fig. 11–6)
●
All curves may be treated
●
Always indicated for double or triple curves
Fusion Levels
●
Single thoracic curves
●
Proximal end vertebra to one level proximal to the
stable vertebra with hook fixation
●
Proximal end vertebra to one or two levels
proximal to the stable vertebra; may often stop at the
distal end vertebra with pedicle screw
●
Double thoracic curves
●
As for single thoracic curves except proximal fixation
is most often to T2
●
Double major curves
Figure 11–4: Cont’d
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