mohammed attiah, mb,ch.b. frcsc assistant professor,orthopaedic surgery uqu

Mohammed Attiah, MB,Ch.B. FRCSC

Assistant Professor,Orthopaedic Surgery UQU

Orthopaedic Specialty Hospital

Jeddah - Saudi Arabia

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Congenital Scoliosis: Treatment Options and Challenges

Review

• Definition

• Spine Growth Facts

• Associated Anomalies

• Natural History

• Challenges

• Decision making

• Treatment Options

• Controversies



Spinal Deformity with the Presence of Vertebral-Anomalies



Congenital Scoliosis

Big Deal, Why?

• Osseous Development

• Neural Element

• Sagittal Natural Curves

• Symmetric Growth



Spine Growth

• Longitudinal GrowthChondro-epiphyseal portion of the end plateEndo-chondral Ossification

Circumferential growth

– Posterior growth ( 5-8 y)• Laminar growth• Pedicular growth

– Anterior Growth(Pre-Pub yrs)

• Latitudinal Growth

Perichondral & Periosteal apposition

Taylor,J. Anat. (1975), 120, 1, pp. 49-68QuickTime™ and a

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Spine Growth Facts ?

In utero = Extremely Accelerated

Birth -2y = Increased Rate

2y - 10 y = Steady Rate

Pre-pub = Increased Rate

Thoracic Vertebra = 0.8 mm /y

Lumbar Vertebra = 1.1 mm /y

Thoracic Disc = 0.2-0.6 mm /y

Lumbar Disc = 0.3-0.8 mm/y

Hefti, JBJS Br, 1983;65:247-54

Dimeglio, Acta Orthop Belg,1990Taylor, J Anat,1975



Thoracic Spine = 1.2 cm/ Year Lumbar Spine = 0.7 Cm / year



Spine Growth Facts ?

Dimeglio, Acta Orthop Belg,1990Taylor, J Anat,1975

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Campbell, JBJS AM, 2004

Wezeka, Spine, 2004

Meehan, J Ped Ortho,1985

Associated Anomalies

• Pulmonary Compromise– Rib Deformity

– Spinal Deformity

– Lung Congenital Abnormality

• Congenital Heart Disease 15 %

– Echo / Cardiology Consult

• CT chest measurement

• PFT volume depletionVC < 50% = Post Op Pulmonary complication

Ferguson, J Ped Orthop ,1996Reckles, JBJS, 1975

• Renal Anomalies 20-40 %

– Unilateral kidney

– Ureteric duplication

– Ureteric obstruction




Renal U/S

Hensinger, JBJS,1974MacEwen, JBJS, 1972

• Spinal Cord Anomalies 20%

– Tethered cord

– Diastemetomyelia

– Fibrous Dural Band

– Intradural Lipoma

– Syringomyelia

– ACM




Spine MRISpine CT scan

McMaster, Spine,1998

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Natural History

McMastar, Spine, 1998Winter, Ortho Clin North Am,1998

• Type of Vertebral Anomalies

• Growth Potential

• Site of Anomalies

Type of Vertebral Anomalies

– Uni Un-segmented Bar+

– Hemi-vertebra



Natural History


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Natural History

Growth Potential

– First 2 years

– Adolescent Growth Spurt


Site of Anomalies

Thoracic > Lumbar



Natural History


• Early stage of life

• Cause large deformity

• Rigid Curve

• Resistant to correction

• Progressive

• Associated anomalies



Congenital Curves Challenges

McMaster, JBJS.1982Fernandes, JBJS,2007

Prediction about what will happen with growth is very difficult

Decision Making



Early Treatment Decision

Magnitude of Curve

Age

Type / Location of Anomaly

Diagnosis

Full Work Up

Consultation

• Balanced Spine

• Stop progression

• Deformity Correction

• Growing Vertebra

• Growing Neural Element

• Torso - Leg ratio



Treatment Goal

What do you want? : What does the spine do?:

• Low Risk for Progression– Cobb angle < 25˚

– RAVD < 20 ˚

• High Risk for Progression– Cobb Angle > 25˚

– RAVD > 21˚



Initiation of Treatment

Mehta, JBJS,Br, 1972

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When to start Treatment

• Anticipated or actual curve progression

– Curve progression 10 ˚

– Initial curve > 30 ˚ at growth spurt stages

Mehta, JBJS,Br, 1972

Treatment Option

• Bracing– Mixed anomalies– Progressive secondary curve

Controlling long,flexible compensatory curve below congenital anomalies

Not Successful Treatment Option



Prevent Future Deformity

In Situ Fusion

Correct Present Deformity

Gradual Correction• Hemiepiphysiodesis• Growing Nonfusion Rod

Acute Correction• Instrumentation & Fusion• Hemivertebra Excision• Osteotomy



Surgical Treatment Options

In situ Fusion

• No hope to get congenitally

fused side growing again

• Simplest & Safest solution

• Stop growth on convex side

– Unilateral Unsegmented Bar

– Balanced

– Not large curve < 40 ˚

– Early stages of life



McMaster, Spine, 1998Dubousset, J Pedi Orthop,1998Keller,lindesth, spine.1994

In situ Fusion Controversy

• Age– Very early years of life?

• Anterior & Posterior fusion– ? Combined

– Less potential anterior growth

– Abnormal anterior vessels

• Trans-pedicular approach

• Decorticating the spine

• Facet Fusion

– One level cephalad

– One level caudad



McMaster, Spine, 1998Dubousset, J Pedi Orthop,1998Keller,lindesth, spine.1994

Prevent Future Deformity

In Situ Fusion

Correct Present Deformity

Gradual Correction• Hemiepiphysiodesis• Growing Nonfusion Rod

Acute Correction• Instrumentation & Fusion• Hemivertebra Excision• Osteotomy



Surgical Treatment Options

FAILURE OF FORMATION

CONCAVE FUTURE GROWTH

I. Single Hemi-vertebra

II. Curve < 50 ˚

III. Age < 5 years



Hemiepiphysiodesis & Hemiarthrodesis

Keller,J Ped Orthop B,1994Winter,J Ped Orthop,1981Andrew, JBJS Br,1985

• Failure to achieve correction

• High failure rate

– 30 % improvement ?

– 40 % no change

– 20 % progressed

Average correction 10˚



Hemiepiphysiodesis Controversy

Roaf, JBJS Br,1963Keller, Spine,1994

Growing Non-Fusion Rod

• Very Young child

• Treat the extended Secondary Curve





Akbarnia,McCarthy,SRS,1994

Growing Non-Fusion Rod

• Primary curve should be addressed:

– In Situ fusion

– Hemiepiphysiodesis

– Excision

– Osteotomy

• Not commonly used technique

• Lack of strong evidence & F/U





Hemivertebra Excision

• Popular procedure

– Immediate

– Excellent – Bradford,JBJS Am,1990

• Remove the Etiology

• Prevent worsening



Correction


• Ideal indication

– Hemivertebra LS junction

– Ignored large curve

• Combined Vs Staged

– Anterior Approach

– Posterior Approach

Leatherman,JBJS

Am, 1996

• Single Approach

– Posterior Excision

– Eggshell procedure




Single Stage Posterior Approach



Complication

• Blood loss

– Segmental

– Epidural

• Neurological injury

– Cord injury

– Root injury

Winter,spine, 1989

Wiles, JBJS Am,1951



Instrumentation & Fusion

• Safe correction

• Balanced spine

• Spinal cord status

• Fusion level selection



8 yrs 9 Yrs

40 80

Downside of Long Segment Fusion

• Crankshaft Phenomenon

– Less anterior growth rate

– No absolute grantee technique

Sanders, JBJS

Am,1995



Spine Osteotomy

• Short Segment Osteotomy



Spine Osteotomy



4040

• Long Segment Osteotomy

– Unacceptable cosmetic

– Fixed deformity

– Unbalanced

• No other solution

• Salvage procedure

• Experienced spinal surgeon

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Principles of Spine Osteotomy

• Cutting through anterior fusion mass

• Resection of enough bone to allow correction

• Temporarily stabilize curve

• Compressive instrumentation allow closure of

osteotomy

• Bone graft ++++

Summary

• Challenges

• Decision making

• Treatment Options

• Safe

• Correct decision

• Long term Follow Up



Orthopaedic Specialty Hospital - OSH



Jeddah - Saudi Arabiawww.osh.med.sa

mohammed attiah, mb,ch.b. frcsc assistant professor,orthopaedic surgery uqu

Documents

thoracic spine

jbjs br

year lumbar spine

ortho clin north

growth spurt stagesmehta

j anat

j ped orthop

ylumbar vertebra