idiopathic scoliosis: a concise approach to scoliogeny theodoros … lecture - a concise... ·...

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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]

Tra

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“Tzaneio

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Piraeus,

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Dr. Theodoros B Grivas MD, PhD

12th International Conference on Conservative Management of Spinal Deformities

5th SOSORT Educational Course, 5-6 May

2015, Katowice - Poland

mailto:[email protected]

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DefinitionsT

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For idiopathic scoliosis (IS)

aetiology means 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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DefinitionsT

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Prof RG Burwell (2013) suggested the word

scoliogeny as the collective noun to

include

1. aetiology,

2. pathogenesis &

3. pathomechanism

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There is a view

there are two

scoliogenic

processes for IS

namely

1. initiating (or

inducing) &

those that cause

2. curve

progression

IS seems to be a multifactorial condition

Burwell et al 2013

Scoliogeny theories, hypotheses & conceptsT

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ce 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 disorder

Neurodevelopmental disorder

Systemic and metabolic disorders involvinga. Platelet calmodulinb. Melatoninc. Melatonin-signaling defect (MSD)d. Osteopontin (OPN) and soluble CD44 (sCD44)e. Oestrogensf. Lepting. Osteopenia

Developmental instability & symmetry control dysfunction

Intrinsic growth plate asymmetry hypothesis

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

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Systemic and metabolic disorders involvinga. Platelet calmodulinb. Melatoninc. Melatonin-signalling defect (MSD)d. Osteopontin (OPN) and soluble CD44 (sCD44)e. Oestrogensf. Lepting. Osteopenia

Developmental instability & symmetry control

dysfunction


Multiple pathogenetic processes: Double neuro-

osseous theory

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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dysfunction



osseous theory

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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dysfunction



osseous theory

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dysfunction



osseous theory

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dysfunction



osseous theory

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dysfunction



osseous theory

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dysfunction



osseous theory

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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 & EpigeneticsT

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The word epigenotype was

introduced by Waddington

(1942) to describe the whole

complex of developmental

processes between genotype

& phenotype, & epigenetics

the name for such studies

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AIS & EpigeneticsT

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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 & EpigeneticsT

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Scoliogenesis of AIST

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AIS & EpigeneticsT

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AIS & EpigeneticsT

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AIS & EpigeneticsT

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AIS & EpigeneticsT

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Tra

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“Tzaneio

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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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idiopathic scoliosis: a concise approach to scoliogeny theodoros … lecture - a concise... ·...

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