Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_31_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

24 Мб

Скачать

☆

<<< < Предыдущая 2 3 4 5 6 7 8 9 10 11 12 1314 / 4514 15 16 17 18 19 20 21 22 23 24 25 26 > Следующая >>>

20 Late Onset Neuromuscular Scoliosis

https://t.me/medicina_free

127

Fig. 20.2 Patient with cerebral palsy (GMFCS V); instrumentation included the pelvis (uneven pelvis; a and b)

A computed tomography scan of the spine (with or without 3D reconstruction) is indicated to study spine, pelvis, and thoracic cage anatomy.

Clinical pictures of the patient before and after surgical treatment are also important.

20.5 Differential Diagnosis

Differential diagnosis is important in the context of the underlying neuromuscular pathology. Conditions associated with NMS include cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy, Friedreich’s ataxia, spina bida, and several genetic syndromes (e.g., arthrogryposis, osteogenesis imperfecta, Larsen syndrome) (Chaps. 14 and 15).

128

https://t.me/medicina_free

F. Canavese

20.6 Treatment Options

In patients with NMS, bracing is usually not effective, and surgery is the primary treatment option (Videos 20.1 and 20.4). The indications for surgery are (1) a signicant curve (exceeding 50°) resulting in functional disturbance, uncomfortable sitting (pelvic obliquity), and/or cardio-respiratory compromise; (2) a progressive spinal deformity not controllable with orthosis; (3) a small curve with inevitable progression; and (4) painful deformities.

Patients with neuromuscular disorders have many similarities in curve patterns, despite different etiologies of the main disease; therefore, similar strategies and common goals are applied to patients with NMS.The goals of surgical treatment are: (1) to prevent curve progression; (2) to maintain the spine balanced on the coronal and sagittal planes, with a level and upright trunk position; (3) to provide a balanced and comfortable sitting position to reduce repositioning; (4) to reduce pain; (5) to reduce the discomfort caused by the impingement of the ribs against the iliac crest on the concave side of the curve; (6) to maximize patients’ health and function; and (7) to maintain walking ability in ambulatory patients.

Surgery can be challenging due to the presence of comorbidities, the need for longer fusions, the frequent need for fusion to the pelvis, the increased bleeding, the longer operative time, the relatively poor bone quality stock, and the higher complication rate.

Luque rods, or variations on the Luque technique, often remain the preferred instrumentation for neuromuscular curves; pedicle screws, hooks, and/or sublaminar polyester bands can also be used (Videos 20.3 and 20.7).

Instrumentation and fusion should be extended to the pelvis in non-ambulatory patients with pelvic obliquity. In contrast, instrumented fusion can stop at L5 or above when the patient is still ambulatory and shows minimal or no signs of pelvic obliquity. Small amounts of pelvic obliquity (less than 10° to 15°) are compatible with comfortable sitting. In contrast, larger xed obliquities are not compatible with comfortable sitting and must be corrected surgically or, if not xed, with wheelchair modications.

20.7 Expected Outcomes

The success of treatment depends on the maintenance of a balanced spine on the coronal and sagittal planes over a level pelvis.

In children with NMS, puberty can begin earlier or, more frequently, later than the puberty of children with idiopathic scoliosis. Depending on the neuromuscular disease, the rate of progression of the scoliotic deformity during pubertal growth spurt can increase by 2°–4° per month, especially in patients who are wheelchairbound. NMS continues to progress beyond skeletal maturity at a rate of approximately 1°–4° per year if the curvature is greater than 50° at the end of growth, compared to approximately 0.5°–1° per year for curves of less than 50°. The

20 Late Onset Neuromuscular Scoliosis

https://t.me/medicina_free

129

risk-to- benet ratio is an important parameter that must be considered before surgery as the results can be gratifying if patients are properly selected.

20.8 Potential Complications

The postoperative complication rate is much higher (approximately 30%) in patients with NMS, compared to patients with idiopathic scoliosis.

Early postoperative complications include deep spine infections (risk 10–20 times higher than in idiopathic scoliosis), cardio-respiratory, neurologic and nutritional issues, prolonged ileus, constipation, uid overload, skin breakdown, bleeding, and death. Late postoperative complications include chronic infections, non-union, coccygodynia, crankshaft phenomenon, implant-related issues, loss of correction, and inadequate correction.

20.9 What Should Patient andFamily Know?

Although spinal surgery can restore proper spinal alignment, it has some potential disadvantages. In particular, spinal fusion and instrumentation can adversely affect those patients with neuromuscular disorders who have developed functional compensation techniques requiring a short and mobile trunk. Moreover, surgery stops any further growth over the fused segments, and it can accentuate hip deformity.

In patients with neuromuscular disease, the likelihood and severity of scoliosis increase with the degree of neuromuscular involvement.

Further Readings

Canavese F, Marengo L, Corradin M, et al. Deep postoperative spine infection treated by nega-

tive pressure therapy in patients with progressive spinal deformity. Arch Orthop Trauma Surg.

2018;138(4):463–9. Lonstein JE, Koop SE, Novachek TF, Perra JH. Results and complications after spinal fusion

for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston

instrumentation: experience in 93 patients. Spine (Phila Pa 1976). 2012;37:583–91. Sharma S, Wu C, Andersen T, Wang Y, etal. Prevalence of complications in neuromuscular scolio-

sis surgery: a literature meta-analysis from the past 15 years. Eur Spine J. 2013;22:1230–49.

Postural Kyphosis

https://t.me/medicina_free

FedericoCanavese andAlpaslanŞenköylü

21.1 Definition

Postural kyphosis (PK) is the most common type of increased thoracic kyphosis (greater than 40°). It is a benign condition characterized by an abnormal rounding of the thoracic spine due to the lack of rigidity in the spine, and the lack of structural abnormalities of the vertebral bodies on plain radiographs.

PK is reducible (exible deformity) by the patient (active correction) or by orthopedic maneuvers (passive correction).

21.2 Natural History

Patients not improving their posture can develop persistent back pain, and rigid kyphosis; the concern is mainly esthetic.

Supplementary Information The online version contains supplementary material available at (https://doi.org/10.1007/978- 3- 030- 80356- 8_21).

F. Canavese (*) Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Lille, France

Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France

A. Şenköylü Department of Orthopaedics and Traumatology, Faculty of Medicine, Gazi University, Ankara, Turkey

https://doi.org/10.1007/978-3-030-80356-8_21

131

132

https://t.me/medicina_free

F. Canavese and A. Şenköylü

21.3 Physical Examination

PK often occurs in adolescents and it can be the result of poor posture and/or muscle weakness. Clinical examination reveals abnormal rounding of the thoracic spine (hyper-kyphosis); the deformity is exible (Fig.21.1a, b). A neurological evaluation includes an assessment of pain, numbness, paresthesia, extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes (Video 21.4).

21.4 Imaging

The radiographic diagnosis of PK is straightforward. Usually, imaging is not needed. However, standard anterior-posterior and lateral radiograph of the spine allows investigating the structure of the vertebrae (vertebral wedging, end-plate irregularities, disk height) and assessing the overall sagittal alignment of the spine (Video

21.6). To evaluate curve exibility, radiographs may be taken with the patient supine (positive response to positional changes).

Complementary investigations, such as magnetic resonance imaging (MRI) and computed tomography scan of the spine, are rarely needed unless different etiology is suspected (presence of warning signs (red ags; Chap. 11)).

Fig. 21.1 A patient’s hyperkyphosis (a) can be easily corrected with hyperextension maneuver (b). This is not possible for the Scheuermann’s kyphosis

21 Postural Kyphosis

https://t.me/medicina_free

133

21.5 Differential Diagnosis

The other causes of abnormal kyphosis are Scheuermann’s kyphosis (Chap. 22), congenital kyphosis (Chap. 24), kyphosis associated with achondroplasia or neuromuscular disorders (Chap. 20), post-traumatic kyphosis (Chaps. 4 and 9), and kyphosis post-laminectomy; moreover, PK is among the causes of back pain in children and adolescents (Chap. 11).

Most of the above-mentioned pathologies are rigid whereas PK is quite exible (Fig.21.1a, b).

21.6 Treatment Options

The treatment of PK in children aims to prevent the curve from worsening and to restore normal posture. The goal of physical therapy is to strengthen the back and abdominal muscles in order to share the load bearer by the spine, improve posture, and reduce discomfort/pain. Some adolescents are resistant to perform exercises given by physiotherapists. In this case, the patient should be encouraged to play sports regularly that he/she enjoys. Especially sport activities such as Pilates, yoga, swimming, and dancing are useful to strengthen paravertebral muscles and help to correct the posture. The key is to choose the type of activity by the patient him/ herself since motivation is the most important variable for continuing the workout.

In skeletally immature patients with more severe deformity and signicant amount of remaining growth (Risser 0–2) (Appendix M), a brace is indicated to support the spine growing into the correct posture (good sagittal alignment). A Milwaukee-type cervico-thoraco-lumbo-sacral brace is the most common orthosis in patients with a thoracic hyper-kyphosis, and it is usually very effective. However, the most substantial drawback of the Milwaukee brace is poor patient compliance due to self-appearance problems.

Nonsteroidal anti-inammatory drugs or pain-killers can help to reduce any discomfort related to abnormal kyphosis.

21.7 Expected Outcomes

Most patients with PK can achieve a good outcome (correction of the kyphosis to within the normal range) with education in proper posture and participation in an exercise program (strengthening of the back and abdominal muscles to reduce discomfort and improve posture).

21.8 Potential Complications

PK is a benign condition. The development of rigid kyphosis and persistent pain not controlled with medication are potential complications related to poor posture and/ or lack of treatment. Breathing difculties and neurological symptoms (numbness

134

https://t.me/medicina_free

F. Canavese and A. Şenköylü

or weakness in the extremities, problems with balance, loss of normal bladder or bowel control) are possible, although rare, complications; if neurological symptoms are detected, MRI of the whole spine is mandatory (Chap. 11).

21.9 What Should Patient andFamily Know?

PK can be prevented by maintaining good posture. Parents should encourage their child to avoid slouching, to sit correctly, to avoid carrying heavyweights, and to take regular physical activities, including breathing exercises. But the behavior of the parents should be more supportive rather than commanding. Backpacks are also another biomechanical factor often implicated as a reason for back pain and poor posture in children and adolescents. Although there is no convincing evidence that supports this hypothesis, children should use school bags properly by arranging straps and putting both handles evenly to their shoulders.