dr. theodoros b grivas md, phd lecture - a... · 2017-05-15 · al 1987, kesling & reinker...

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Idiopathic Scoliosis:A concise approach

to scoliogeny

Traumatology & Orthopaedic Department, "Tzaneio" General Hospital of Piraeus– NHS, Tzanni & Afendouli str,

18536, Piraeus, Greece,[email protected]

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Dr. Theodoros B Grivas MD, PhD

11th International Conference on Conservative Management of Spinal Deformities4th SOSORT Educational Course, 6-7 May

2014, Wiesbaden (Germany)

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DefinitionsTr

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For idiopathic scoliosis (IS)

aetiologymeans the factor(s) causing the IS

pathogenesis the mode of origin of the morbid process, &

pathomechanism the sequence of events in the evolution of its structural & functional changes that result from the pathological process

aetiopathogenesis embrace aetiology & pathogenesis

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DefinitionsTr

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Prof RG Burwell (2013) suggested the word

scoliogeny as the collective noun to include

aetiology,

pathogenesis &

pathomechanism

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There is a view there are two scoliogenic processes for IS namely

initiating (or inducing) &

those that cause curve progression

IS seems to be a multifactorial condition

Burwell et al 2013

Scoliogeny theories, hypotheses & conceptsTr

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aum

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ece Relative anterior spinal overgrowth (RASO)

Asynchronous spinal neuro‐osseous growthThoracospinal conceptDorsal shear forces & axial rotation instabilityFlexural‐torsional buckling from flexibility anisotropyBiomechanical spinal growth modulationBiomechanical theoryIntervertebral disc (IVD) disorderDeforming three joint complex hypothesisMotor control disorderSensorimotor integration disorder & dystoniaSensory integration disorderVestibular disorder

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Body spatial orientation disorderNeurodevelopmental disorderSystemic and metabolic disorders involving

a. Platelet calmodulinb. Melatoninc. Melatonin‐signaling defect (MSD)d. Osteopontin (OPN) and soluble CD44 (sCD44)e. Oestrogensf. Lepting. Osteopenia

Developmental instability & symmetry control dysfunctionIntrinsic growth plate asymmetry hypothesisMultiple pathogenetic processes: Double neuro‐osseous theory

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Relative anterior spinal overgrowth (RASO)Asynchronous spinal neuro‐osseous growthThoracospinal conceptDorsal shear forces and axial rotation instabilityFlexural‐torsional buckling from flexibility anisotropyBiomechanical spinal growth modulationBiomechanical theoryIntervertebral disc disorderDeforming three joint complex hypothesisMotor control disorderSensorimotor integration disorder & dystoniaSensory integration disorderVestibular disorder

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Relative anterior spinal overgrowth (RASO)Asynchronous spinal neuro‐osseous growthThoracospinal conceptDorsal shear forces and axial rotation instabilityFlexural‐torsional buckling from flexibility anisotropyBiomechanical spinal growth modulationBiomechanical theoryIntervertebral disc (IVD) disorderDeforming three joint complex hypothesisMotor control disorderSensorimotor integration disorder & dystoniaSensory integration disorderVestibular disorder

• Elevated synthetic activity in the convex side of scoliotic IVD & endplates compared w/ normal tissues• The elastic fiber network of the annulus fibrosus of the normal & scoliotic human IVD• Accelerated IVD degeneration in scoliosis versus physiological ageing develops against a background of enhanced anabolic gene expression• Cobb angle progression in AIS begins at the IVD

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an abnormal pattern of brain activation in secondary motor areas during movement execution in patients with IS. The hypothesis is that a sensorimotor integration disorder underlies the pathogenesis of IS

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A dystonic dysfunction underlies in IS. Asymmetrical cortical hyperexcitability may play an important role in the pathogenesis of IS & represents an objective neurophysiological finding that could be used clinically

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The severity of scoliosis in scoliotic girls could be related to an increase in the sensory integration disorder

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The are detected morphoanatomical changes which are likely to be associated with subclinical postural, vestibular and proprioceptive dysfunctions reported frequently in AIS, as it was demonstrated in MRI‐based morphoanatomy clinical studies of vestibular system

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a. Platelet calmodulinb. Melatoninc. Melatonin‐signalling defect (MSD)d. Osteopontin (OPN) and soluble CD44 (sCD44)e. Oestrogensf. Lepting. Osteopenia


two stage hypothesis:the natural history of AIS involves an initial stage in which a small curve develops due to a small defect in the neuromuscular control system and a second stage during adolescent growth in which the scoliotic curve is exacerbated by biomechanicalfactors

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curve initiation process

rapid spinal elongation in adolescent growth spurt

maturational delay of CNS body schema

movements of spine and trunk, upright posture

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Normal puberty

Onset of AIS

Curve Progression & Severity

Predisposition genes/ initiation genes

Disease modifier genes/ progression genes

AIS Initiation Factors

AIS Progressive factors

Environmental factors

epigeneticsepigenetics

epigenetics

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epigenetic differences may underlie scoliotic MZ twin discordance, & represent the link between environmental factors & phenotypic differences.

AIS & EpigeneticsTr

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The word epigenotype was introduced by Waddington (1942) to describe the whole complex of developmental processes between genotype& phenotype, & epigeneticsthe name for such studies

AIS & EpigeneticsTr

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AIS & EpigeneticsTr

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Environmental risk factors for AIS • Monozygotic twins & spinal radiology in AIS ( Wynne-Davies 1968, Smyrnis et al 1987, Kesling & Reinker 1997, Inoue et al 1998, van Rhijn et al 2001, Fraga et al 2005, Martin 2005, Andersen et al 2007, Hermus et al 2007, Miller 2007, Kaspiris et al 2008, Sales et al 2010, Wong et al 2010, Grauers et al 2010, Day and Sweatt 2011)

• A food & growth connection (Golding 1991, Worthington & Shambaugh 1993, Enwonwu & Sanders 2001, Kaati et al 2002, Veyver 2002, Burwell 2003, Burwell and Dangerfield 2004 Bjornsson et al 2004a, Feinberg 2007, Feinberg 2008, Greene et al 2011, Ford et al 2011, Francis 2011)

• Relative osteopenia & life-style factors (Hung et al 2005, Lam et al 2011, Wang et al 2011)

• Physical activities of patients with AIS (Bagnall 2000, McMaster et al 2004, 2006)

• Geographic latitude & the prevalence of AIS (Grivas et al 2006)

• Maternal age & socio-economicstatus (De George and Fisher 1967, James & Wynne-Davies 1969, Ryan & Nachamson 1987, Heijmans et al 2009, (Grivas et al 2012)

• Heated indoor swimming pools infants and delayed epigenetic effects (McMaster et al 2004, 2006, McMaster 2011)

• Hypothesis of developmental instability for scoliosis (Goldberg 2000, Bjornsson et al 2004, Gluckman & Hanson 2006, Feinberg 2008, Gluckman et al 2011)

AIS & EpigeneticsTr

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Scoliogenesis of AISTr

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AIS & EpigeneticsTr

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AIS & EpigeneticsTr

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AIS & EpigeneticsTr

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AIS & EpigeneticsTr

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AIS & EpigeneticsTr

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Trau

mat

olog

y &

Orth

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dic

Dep

artm

ent “

Tzan

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Gen

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Hos

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l of P

iraeu

s,

Gre

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Traumatology and Orthopaedics Department

“Tzaneio” General Hospital of Piraeus, 2014

T z a n e i o H o s p i t a l 1 8 6 4

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dr. theodoros b grivas md, phd lecture - a... · 2017-05-15 · al 1987, kesling & reinker...

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