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DEFORMITIES OF SPINE

ANATOMY OF SPINE

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KYPHOSIS
A. DEFINITION
Kyphosis is the normal spine profile of the thoracic region of the
spinal column. It originates from the Greek word kyphos, meaning
“humpbacked,” and refers to a curve pointing backward (that is, the apex
of the curve is posterior). The normal range of thoracic kyphosis is 20° to
50° (Cobb angle from T3 to T12), and values greater than 50° are
considered hyperkyphotic. 1

Figure 1.
Scheuermann thoracic kyphosis: clinical photograph.2

Postural kyphosis and Scheuermann disease are the most common
causes of hyperkyphosis, and both present during adolescence. Postural
kyphosis is a flexible deformity that is more common in girls, and patients
are able to correct the kyphosis voluntarily. Scheuermann disease, in
contrast, is more common in boys and is not passively correctable.
Scheuermann disease is diagnosed radiographically as a hyperkyphosis
associated with anterior wedging of more than 5° in at least three
successive vertebrae, usually with disk space narrowing, irregularities of
the vertebral end-plates, and Schmorl nodes (herniations of disk material
through the vertebral end plates). The etiology is unclear, but a familial
incidence is noted in 30% to 48% of cases. 1,3

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It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis. In the young. and may become apparent in infants and toddlers. Scheuermann's kyphosis is considered a form of juvenile osteochondrosis of the spine. and thoracolumbar Scheuermann’s disease has an apex at T1112. it may be a case of hyperkyphosis and called 'dowager’s hump'. normally attributed to slouching. Thoracic Scheuermann’s disease has an apex of the curve at T7–9.8 Clinically. Scheuermann's kyphosis Significantly worse cosmetically and can cause varying degrees of pain. About one third of the most severe hyperkyphosis cases in older people have vertebral fractures. Postural kyphosis The most common type. 2. can occur in both the old4 and the young. Pain is usually aching and occurs more commonly with the thoracolumbar form. CLASSIFICATION 1.6 and hyperkyphosis can develop due to aging alone.5 Otherwise. it is possible to distinguish two forms of juvenile kyphosis. and is more commonly called Scheuermann's disease. the aging body does tend towards a loss of musculoskeletal integrity. Congenital kyphosis 4 .1 B. In the old. A patient suffering from Scheuermann’s kyphosis cannot consciously correct posture. Cosmetic deformity is often the chief complaint. it can be called 'slouching' and is reversible by correcting muscular imbalances. and can also affect different areas of the spine (the most common being the midthoracic area).3 3. the other forms of kyphosis may be diagnosed throughout childhood and adolescence.Congenital kyphosis implies a structural defect in vertebral formation.

Radiographic findings a. Vertebrae may be malformed or fused together and can cause further progressive kyphosis as the child develops. Scheuermann postulated that the condition resulted from avascular necrosis of the apophyseal ring.9 C. DIAGNOSIS 1. PATHOPHYSIOLOGY The pathophysiology of kyphosis depends on the etiologic factor.It can result in infants whose spinal column has not developed correctly in the womb.11 A Danish study demonstrated an important genetic component to the entity. Other theories include histologic abnormalities at the endplate. The exact cause of Scheuermann disease is still imprecisely defined. Excessive kyphosis b.12 D. Three sequential vertebra with more than 5 degrees of wedge 5 .10 and mechanical factors that affect spinal growth. osteoporosis.

whereas patients with postural kyphosis have a more gentle curvature. Neurologic changes are rare: MRI indicated if they are present13 E. the spine flattens in the supine position). Patients with postural kyphosis have normal flexibility (ie. More common in boys b. Affected patients usually overweight c. especially when the deformity is 6 . Adolescents with Scheuermann disease and other pathologic causes of kyphosis usually have a sharp angulation at the apex of the kyphosis. Kyphosis is not postural: does not complete correct with hyperextension d. The neurologic examination is usually normal in postural hyperkyphosis and Scheuermann disease but may be abnormal with other forms of kyphosis.Anterior wedging of thoracic spine in a 15-year-old boy with Scheuermann kyphosis 2. Physical Examination Hyperkyphosis is apparent when viewing the patient from the side. and the deformity is increased on the Adam forward bend test (Figure 1). Clinical characteristics a.

and these curves are unlikely to progress. but other forms of kyphosis 7 . The angle is formed by the intersection of a line drawn along the superior end plate of T5 and a line drawn on the inferior end plate of T12. F. disk spaces. Diagnostic Tests AP and lateral radiographs of the entire spine should be obtained with the patient standing. The reviewer should look for congenital abnormalities as well as irregularities of the vertebrae. When the upper thoracic vertebrae cannot be well visualized. Hamstring spasm and/or contracture are common with pathologic forms of hyperkyphosis.severe. kyphosis should be measured from T5 to T12. and the end plates. The curve magnitude is measured on the lateral radiograph using the Cobb method. G. Any curvature exceeding 50° is considered abnormal. Complication The natural history of flexible or postural hyperkyphosis is benign.

Milwaukee brace or equivalent). seen with curvatures greater than 90° to 100° (restrictive pattern). SCOLIOSIS A. and progressive deformities often require surgical stabilization. neurologic symptoms. and a subset of patients with progressive and symptomatic curvatures greater than 70° are candidates for a posterior or an anterior/posterior spinal fusion with instrumentation. Introduction 8 . Progressive curvatures due to Scheuermann disease may be treated by a bracing program in patients who are skeletally immature (fulltime wear. Congenital kyphosis is much more likely to require surgical intervention. Bracing is not effective in patients with congenital deformities. Treatment Postural kyphosis can be observed or treated with an exercise program. rarely. and a decrease in pulmonary function. usually seen with congenital kyphosis. The consequences of a progressive kyphosis may include back pain. H. sometimes in the first few years of life.present a significant risk for progression.

coronal. resulting from tilting of the pelvis from real or apparent shortening of one leg. which are dependent on the relative contributions of these two deformities. These conditions may be accompanied by compromise of the spinal nerve roots and/or the spinal cord. Sagittal plane malalignment of the spine may involve any region of the spine but is most common in the thoracic and thoracolumbar spine and is common with aging. Sagittal plane deformity or kyphotic deformities of the spine are best seen on physical examination from the side with the patient bending forward. spinal cord lesions. the first and most important decision to make is whether there is any deformity of the vertebrae (structural scoliosis). and osteoporosis. Spondylolisthesis (isthmic) usually occurs at the lumbosacral joint and is accompanied by tight hamstring muscles (inability to toe-touch). Patients with a new onset of scoliosis or rapid progression of deformity should be evaluated for syndromes or diseases that may be a cause of spinal deformity such as neurofibromatosis. scoliosis is usually idiopathic. A rapid progression of deformity in the adult may be an indication of neoplasm or infection. or a tethered spinal cord. but there is often a degree of associated kyphosis. but there is a concordant rotational deformity that is apparent on examination. Trunk rotation or rib prominence on forward bending (Adam forward bend test) is a critical measure of axial plane deformity and may be apparent earlier than coronal deformity in patients with scoliosis. If the vertebrae are normal (non-structural scoliosis) the deformity is usuall due to one of the following conditions: it may be compensatory. is common and may be associated with aging. Scoliosis is defined by coronal plane deformity. or de novo degenerative scoliosis. but in older patients it also may occur as a result of degenerative changes. Scoliosis is primarily a lateral curvature of the spine. Shoulder asymmetry. segmental instability. and axial planes. Mathematical analysis of the curves has revealed several distinct patterns. In the management of any case. Onset of a spinal deformity in adulthood.Spinal deformity may affect the sagittal. In younger patients. pelvic tilt. and asymmetric abdominal or flank creases are signs of deformity in the coronal plane. It may be sciatic and due to unilateral protective muscle 9 .

especially that accompanying a prolapsed intervertebral disc. B. may contribute to and/or confound the symptoms and progression of either condition. Current theorists believe that scoliosis is a multigene dominant 10 . C. D. Multiple abnormalities have been found. degenerative disk disease. Defenition Scoliosis is a lateral curvature of the spine. In adults. Postural scoliosis occurs most commonly in adolescent girls and generally resolves spontaneously. Scoliosis in girls tends to progress more often and. Epidemiology Scoliosis is present in 2 to 4 percent of children between 10 and 16 years of age. the rate of curve progression is nearly identical among twins subjected to a variety of environmental influences. the condition is classified as either a deformity that developed during childhood or a deformity that developed after skeletal maturity. Indeed. spinal stenosis. The ratio of girls to boys with small curves of 10 degrees is equal but increases to a ratio of 10 girls for every one boy with curves greater than 30 degrees. therefore. The prevalence of curves greater than 30 degrees is approximately 0.spasm. and the prevalence for curves greater than 40 degrees is approximately 0. and degenerative spondylolisthesis. including osteoporosis. a recent meta-analysis showed that not only is the risk for scoliosis greater in monozygotic twins than in dizygotic twins. girls more commonly need treatment than boys. Improved understanding of the natural history and prognosis of this disease can help the physician predict the patients with scoliosis who need treatment. Pathogenesis Many studies have attempted to uncover the pathophysiologic process underlying idiopathic scoliosis. Changes that occur with aging.1 percent. Studies of twins have given the firmest indication that the most significant factor is genetic.2 percent. yet none has been conclusively linked to all cases. usually secondary to degenerative spondylosis and/or degenerative spondylolisthesis.

asymmetric disk degeneration. In some patients. or that they are leaning to the side more. including both idiopathic and neuromuscular curves. Neurologic changes are infrequent but most commonly involve the extensor hallucis longus muscle. Defenition Congenital scoliosis is a progressive three-dimensional deformity of the spine caused by congenital anomalies of the vertebrae that result in an imbalance of the longitudinal growth of the spine. Therefore. the risk that their children will require treatment is 50 times that in the general population E. Because age-related changes in the spine are present in nearly everyone. F. Cardiopulmonary decompensation rarely is evident in adultonset scoliosis. When both parents have scoliosis. Clinical Findings The most common presenting symptom is pain localized to the region of the deformity. it is important to understand the embryologic development of vertebrae. Radicular pain is most commonly associated with compression of the L4 or L5 nerve root due to asymmetric hypertrophy of the facet joints. a thorough evaluation is required to identify the most likely source of pain.” These patients may also report that the “hump” on their back is getting bigger. which may also cause lower lumbar pain. Symptoms related to pulmonary compromise are associated with more severe thoracic curves. 11 .condition with variable phenotypic expression. The most common overlapping syndrome is degenerative spondylosis. and mild rotatory subluxation. its severity can vary widely from parent to child and sibling to sibling. To understand their natural history and their treatment. even though scoliosis is typically present in most members of the same family. Classification Congenital Scoliosis A. the chief presenting symptom is a progressive spinal deformity Some report that they are “getting shorter.

The hemivertebra is “carved into” the adjacent levels. In many cases. Segmented hemivertebra: Both the superior and the inferior ends of the hemivertebra have growth potential. The shape of adjacent vertebrae is normal. Hemivertebrae are classified according to their longitudinal growth potential. causing a bar (Fig. The hemivertebra is completely fused with vertebrae above and below. Classification Two types of basic vertebral anomalies can occur: failures of formation and failures of segmentation. b) Failures of Segmentation Failure of segmentation (type II deformity) can be partial. a) Failure of vertebral formation Failure of vertebral formation (type I deformity) can be partial. but the adjacent vertebrae compensate for it. causing a block vertebra. posterior. d. The other end is fused with the adjacent vertebra. or mixed. causing a wedged vertebra with intact pedicles (Fig. which in normal vertebrae is provided by growth apophyses on both vertebral ends. or complete. A congenital bar can be anterior. Nonsegmented hemivertebra: There is no growth potential. c. 22–4). causing a hemivertebra with a unilateral pedicle (Fig. or complete. a. lateral.B. 22–3). Semisegmented hemivertebra: Either the superior or the inferior end of the hemivertebra has growth potential. 22–2). vertebral anomalies owing to failures of formation and failures of segmentation 12 . b. Incarcerated hemivertebra: Both the superior and the inferior ends of the hemivertebra have growth potential.

occasionally on several levels. The etiologic theories are clouded further by the finding of an increased incidence of idiopathic scoliosis in families with congenital scoliosis. but the familial incidence in the congenital scoliosis population is typically 1% to 5%. the role of genetic and environmental factors is often reported. The precise etiology of congenital scoliosis is unclear. Environmental factors have also been implicated in the genesis of congenital scoliosis. and form a mixed deformity (type III deformity). Maternal acute carbon monoxide exposure during somite formation induces vertebral anomalies in the offspring of mouse and rabbit models. The genetic role has been reported in cases of congenital scoliosis in twins. 13 . The mechanism of carbon monoxide action remains vague. in contrast to idiopathic scoliosis. more recently. Its true incidence is unknown. Carbon monoxide could act directly on the cartilaginous spine via resulting hypoxia or a gene mutation. but.coexist. Etiology Congenital scoliosis is uncommon in the general population. with a ratio of 3 : 2. C. It is slightly more common in girls than in boys. Although most cases seem to be sporadic. several studies have isolated gene mutations. however.

shoulder malalignment. it is crucial to assess and document the neurologic status. In addition. Curves with segmented hemivertebrae are at risk for progression during growth because segmented hemivertebrae act as enlarging wedges (Fig. Without any treatment. The examination should begin with an assessment of a patient’s existing balance: sagittal plane balance and coronal balance. and any deviation of head and trunk from the center of the pelvis. The natural history of congenital scoliosis has to take several factors into account:  Type of anomaly  Location  Number of anomalies  Initial severity of the scoliosis  Global growth potential balance between each side of the Spine Physical Examination The physical examination of a patient with congenital scoliosis is guided by the knowledge of a heightened incidence of other structural and neural anomalies. The location of the anomaly also plays a part in the evolution of scoliosis. and presence of any atrophy. congenital scoliosis progresses in 70% of patients during growth. a wedge vertebra has only a slight risk of worsening. 22–6). Flexibility of the 14 . reflexes. whereas a complete block or an incarcerated hemivertebra does not cause any progressive scoliosis. Conversely. about 85% of patients with congenital scoliosis have a curve greater than 41 degrees by maturity. including strength. whereas the least severe are located at the upper thoracic spine. The potential for increase in curvature is related to imbalances in the number of growth apophyses and the location of vertebral anomalies. Diagnosis Anamnesis As with scoliosis of any etiology. The most progressive anomaly is a convex segmented hemivertebra associated with a concave unilateral bar because there is absolutely no growth potential on the side of the bar. The most severe anomalies are those located at the thoracolumbar region.D.

C. Right thoracic curve and 15 . should be localized and quantified. gait. and limb-length inequality should be checked. It is easier to analyze segmented hemivertebra (A) or unilateral bar (B) when films are taken before 4 years of age than after. Lumbar segmented hemivertebra in a 9-year-old child FIGURE 22–5 Congenital scoliosis with VACTERL association managed by observation since birth. The examiner should search for other anomalies of the extremities (particularly radial malformation) and range of neck motion. if present. Pain. A and B. Radiology  CT Scan  MRI A and B. The presence of a dimple or any cutaneous mark on the back should be noted.deformity.

For a few cases with long and flexible curves. with or without deformity reduction. The only potentially useful treatment is bracing of the noncongenital components of a flexible curve. In contrast to idiopathic scoliosis. progression of scoliosis can be slowed by bracing. Treatment Non Operative Congenital vertebral anomalies require close clinical monitoring at periodic intervals during growth. convex hemiepiphysiodesis. Treatment of congenital scoliosis consists of two options: (1) clinical monitoring of static vertebral anomaly and (2) operative treatment of worsening scoliosis. nonoperative treatment has little value in congenital scoliosis. bracing is rarely. however Given the significant time period remaining before skeletal maturity. and guided growth by vertical expandable prosthetic titanium rib (VEPTR) or growing rods. The main principle of operative treatment is to balance growth. hemivertebra excision. Idiopathic Scoliosis A. Defenition 16 . Spinal curves in congenital scoliosis are often short and rigid. Operative Congenital scoliosis develops because one side of the spine is growing faster than the other. In complex malformations. E. early treatment is often more straight forward and safer. Five major operations have been described: posterior spine fusion.compensatory lumbar curve remain relatively unchanged from birth at 1 year of age (A) and at 8 years of age (B). more than a temporizing solution. combined anterior and posterior spine fusion. if ever. Consistent observation allows for assessment of the evolution of spinal curves.

juvenile (3 years to 9 years + 11 months).3 In contrast to infantile idiopathic scoliosis. with about 5% of curves showing progression of greater than 30 degrees. typically occurring in boys. neuromuscular (developmental or acquired). Presently. using the Cobb method.Idiopathic scoliosis is the most common cause of spinal deformity 80% of all scoliosis cases are due to idiopathic scoliosis. 17 . B. Epidemiology Infantile and juvenile scoliosis are less prevalent than adolescent idiopathic scoliosis. Infantile idiopathic scoliosis is more common in Europe. inflammatory or infectious. More recent reviews suggest that there might be a decline in its incidence. Before arriving at the diagnosis of idiopathic scoliosis in a patient. Between the ages of 3 and 6 years. based on spinal growth velocity noted in these two age groups. The radiographic diagnosis necessitates measuring the coronal plane angle. however. the prevalence of 10-degree curves is less than 3%. as equal to or greater than 10 degrees. Patients with curves less than 10 degrees are considered to have spinal asymmetry. juvenile cases tend to occur predominantly in girls and tend to comprise right-sided curves. Ponseti and Friedman1 first described early-onset scoliosis in 1950. again becoming predominant in girls after age 6 years. idiopathic scoliosis is divided into three categories based on chronologic age: infantile (birth to 2 years + 11 months). pathologic. have to be discounted. other causes. and tends to comprise leftsided thoracic curves. functional. Juvenile cases are typically diagnosed at age 7 years in girls and 5 years in boys and account for about 10% to 20% of idiopathic scoliosis cases. constituting less than 1% of idiopathic scoliosis cases in the United States. Dickson expounded further on that concept and proposed that idiopathic scoliosis be divided into early (0 to 5 years old) and late onset (>5 years old). such as congenital. Adolescent idiopathic scoliosis is more prevalent than other types of idiopathic scoliosis. and intraspinal. Among adolescents. and adolescent (10 years to 17 years + 11 months). there seems to be a similar distribution between boys and girls.

a thorough prenatal and birth and developmental history is obtained. Age at onset of menarche and voice changes in boys are noted as well because they are likely predictors of growth potential and possible curve progression. with a 4 : 1 ratio of girls to boys. that in the observed deformation of the spine. if any at the time of presentation.This prevalence decreases as a function of curve magnitude. D.5% and 0. and muscle structural changes. The literature suggests. Etiology Infantile scoliosis occurs roughly in 1 of 10. genetics and the unique mechanics of the fully erect posture. play an important role. The growth spurt noted among adolescents seems to play a role in progression. Possible causes are thought to occur from intrauterine molding or postnatal pressure on the spinal column from supine positioning while sleeping. The prevalence of curves greater than 10 degrees is higher among girls. and any family history of scoliosis is noted. In a review of the literature.000 births. Kouwenhoven and Castelein13 concluded many factors may play a role in the initiation and progression of adolescent idiopathic scoliosis at a certain age. Symptoms of or weakness and how the patient perceives his or her appearance relative to the deformity are especially important with adolescent idiopathic scoliosis. In adolescent cases. as a critical buckling load is reached on the existing curve as the spine grows. Diagnosis Anamnesis and Physical Exam A complete history and physical examination is completed. to about 0. 18 . This information is imperative in determining peak growth velocity and its implications on curve progression.3% to 0. hormonal. however. which is exclusive to humans. Other etiologic factors that have been considered in idiopathic scoliosis include dysfunction in proprioception to maldevelopment in central pattern generators in the spinal cord9-11 and connective tissue. however.12 More recent reports in the literature strongly suggest a genetic link. is noted.1% in curves measuring 20 degrees and 40 degrees. C. With infantile and juvenile cases in particular. growth spurt history.

27 Finally. or pelvic asymmetry is noted. Infection. height. and spondylolisthesis also must be discounted. Possible conditions and anomalies that might be present are buccal and palatal anomalies. 19 . such as congenital. breast.During the examination. A thorough neurologic examination is performed. Leg-length discrepancy and pelvic obliquity are evaluated. especially in infants. and gait. Alternatively. Trunk shift is evaluated with the patient standing and the hips and knees fully extended. This assessment is modified in infants by laying the patient on the examiner’s knee. The latter maneuver can also help rule out plagiocephaly and developmental hip dysplasia. Limb laxity is also checked. weight. often associated with Chiari malformations. a shoe lift is used to reevaluate the patient to determine if the curve corrects. The relationship of the patient’s head to the pelvis is also noted in evaluating the overall coronal and sagittal balance. This test also helps assess the rigidity of the curve. motor strength. The neurologic examination includes all cranial nerves. Any shoulder. The head is examined with special attention to torticollis and plagiocephaly because the latter has been associated with higher incidence in infantile scoliosis. and genetic counseling and testing is requested when laxity is present. reflexes (including abdominal reflexes). a sitting forward test can be performed. sensory modalities. other possible causes of scoliosis. must be ruled out. which is an important factor in terms of prognostication. and syndromic types. and midline dimples or hair patches or both over the lumbodorsal spine. Curve rotation is assessed by performing an Adams forward-bend test and is quantified with a scoliometer. neuromuscular. When leglength discrepancy is the likely cause of the deformity. and age (years plus months since last birthday) are recorded. which can be important clinical clues that an intraspinal pathologic process might be present. café au lait spots. neoplasms.

(Right) A rotational deformity known as a rib hump (arrow) can be easily identified . and the Cobb angles are measured. 20 . a neurosurgical consultation is indicated. Radiographic Posteroanterior and lateral 36. sharp angular or irregular curve patterns require further investigation. (Left) As the patient bends over. including screening total spine magnetic resonance imaging (MRI). and left-sided. the examiner looks from behind and from the side. Adam’s forward bend test.FIGURE 3. Curves greater than 20 degrees in infants and children. neurologic symptoms in all patients with idiopathic scoliosis.× 14-inch long cassette views including bending films with appropriately placed bolsters for further curve classification and planning bracing or surgical intervention are obtained. horizontally along the contour of the back. When anomalies of the nervous system are present on MRI.

. phase I or II). A girl age 2 years + 9 months who presented with severe infantile-onset idiopathic scoliosis FIGURE 23–4 A and B. but they can progress.41 Deciphering which curves will progress can be guided by the RVAD and the relationship of the apical rib head to the vertebral body (i.FIGURE 23–3 A and G.22 21 . A boy age 7 years + 9 months who presented with progressive juvenile-onset right thoracic idiopathic scoliosis E. these curves have been known to resolve spontaneously up to 90% of the time. Treatment Non operative Observation Most infantile curves are left-sided.e.

With infantile cases. which can have future ramifications. and deciding which brace to use depends on the apex of the curve and physician preference. curves less than 20 degrees are expectantly followed every 6 to 8 months. They reported that curves less than 60 degrees often fully corrected in infants if casting was started before age 20 months. bracing can control the curve and avoid progression. Bracing is usually started the first office visit when the patient is skeletally immature (Risser ≤2) and presents with a 25.Typically. Juvenile curves more often require operative intervention.to 40-degree curve. Several brace options exist. however. curves with apices at T7 or below and above L2 do well in 22 . whose growth potential remains a significant issue. Bracing and casting of these patients comes with potential consequences. Conversely. however. In a younger child. For curves between 20 degrees and 30 degrees. Adolescents with curves less than 20 degrees at presentation are observed and followed at 4-month and 6-month intervals. Sanders and colleagues found serial casting to be beneficial in the treatment of infantile scoliosis. In about 75% of cases. Treatment is also started for a progression of 5 degrees or greater in two consecutive visits or 10 degrees or greater in one follow-up visit. Curves with an apex above T6 would likely require the use of a Milwaukee (cervicothoracolumbosacralorthosis) brace. rendering the curve small enough so that the risk of progression after growth is unlikely. Bracing and Casting Bracing is the nonoperative treatment of choice in small but progressive scoliosis in growing children and teens. bracing allows for continued growth until the patient requires eventual operative treatment because of curve progression. Infants with curves less than 25 degrees and RVAD less than 20 degrees and children with curves less than 25 degrees should be followed clinically and radiographically every 6 months. Treatment is instituted for curves greater than 25 degrees. that include pulmonary restriction. bracing is started if a curve progresses 5 degrees or more in two consecutive visits or 10 degrees or more in one visit. molded casting followed by bracing used to be the mainstay in nonoperative management.

Common features of neuromuscular scoliosis include the following:  Large curves early in life: Early neuromuscular insult predisposes patients to rapidly progressive scoliosis. and these braces are more socially acceptable because of the lack of a cervical extension. and some studies have shown its efficacy. The Charleston bending brace is an option if the child is noncompliant to bracewear. Children are typically more prone to curve progression and are more likely to require operative intervention. Neuromuscular Scoliosis A. operative intervention is controversial.50 The efficacy of a brace seems to depend on the length of time the brace is worn.49. When bracing is initiated and pad placement is deemed appropriate. Other patients who are likely to benefit from operative intervention are skeletally immature patients with adolescent idiopathic scoliosis with a greater than 40. This brace is typically worn at night. In infants.  Stiff curves: These patients are more likely to develop stiff curves because of the early onset of neuromuscular deficiency resulting in limited mobility and secondary contractures.a Boston underarm thoracolumbosacral orthosis brace. Despite the various conditions that fall in this category. Operative Operative intervention is usually recommended for patients whose curves progress despite nonoperative management. patient follow-up occurs every 4 to 6 months. neuromuscular disorders involve neurologic or muscular deficiencies that produce progressive multiplanar skeletal deformities. Introduction Neuromuscular disorders commonly lead to spinal deformities that are some of the most challenging treatment dilemmas addressed by spine surgeons.to 45-degree curve and mature patients with curves greater than 50 degrees. it is occasionally performed in infants with curves greater than 45 degrees or thoracolumbar/lumbar curves greater than 40 degrees. 23 . with in-brace radiographic evaluation and appropriate fitting adjustments made when necessary.

although many lose their ability to walk early in life or never achieve ambulatory status at all.  Sagittal plane deformity: Gravity and muscular deficiency can also lead to sagittal plane deformity. is rapidly progressive. The use of a wheelchair affords these patients educational and social opportunities that enrich their lives. which may impair comfortable sitting for these patients.. Progressive curves: As in idiopathic scoliosis. Increasing weakness or persistent muscle imbalance around the spine in patients with neuromuscular disorders can cause progression of scoliosis independent of growth. C.  Long curves: Less severely affected individuals may have an S-shaped curve with well-balanced double curves. Classification The classification of neuromuscular scoliosis can be based on the underlying disorder: neurologic (e. the potential for curve progression is greatest during rapid growth and with loss of ambulation.g. Some patients are capable of ambulation. muscular dystrophy). including thoracic or lumbar hyperkyphosis or lumbar hyperlordosis.g.  Pelvic obliquity: Lower extremity contractures and imbalanced spinal deformity cause pelvic obliquity. Neurologic deficiencies can be broken down further into upper motor neuron dysfunction. as seen in spinal muscular atrophy (SMA). Natural History Neuromuscular scoliosis generally begins early in life. or lower motor neuron dysfunction. as seen in myelomeningocele. however. Unbalanced curves and significant pelvic obliquity make wheelchair positioning difficult and may cause uneven distribution of weight that may 24 . B. cerebral palsy) or muscular (e. Spinal deformity can impair comfortable sitting and dramatically reduce the individual’s quality of life. and causes significant morbidity.. Patients with neuromuscular disorders are challenging because of the complexity of their deformity and fragility of their overall health and are best treated by an experienced surgeon with support from a multidisciplinary team. Long C-shaped curves are more likely in severely affected patients with resultant sitting imbalance.

feeding. and hygiene. When patients with neuromuscular scoliosis lose the ability to sit comfortably. D. The ultimate goal of treatment of patients with neuromuscular scoliosis is the maintenance of as much independence and function as possible. more rigid curves in adolescent idiopathic scoliosis apply to the treatment of neuromuscular scoliosis. Prominences created by the convexity of a curve may result in skin breakdown. creases within the concavity of the trunk deformity are susceptible to skin maceration and infection. positioning. 25 . functional decline. Eventually. Large rigid curves restrict lung volume and impair respiration in patients who often already have limited pulmonary capacity. Majd and colleagues showed a correlation between deformity size. flexible curves and surgically fusing larger. Observation alone is employed until curves begin to cause functional impairment. Treatment The basic principles of observing or bracing smaller. and decubitus. used primarily to provide sitting support while the patient grows.lead to pressure sores. improving the ease of transfers. Treatment of neuromuscular scoliosis can also help the caretakers of these patients. their quality of life is dramatically decreased. many of these patients require surgical stabilization with a spinal instrumentation and fusion procedure. Bracing can be a temporizing measure. The natural history for a given patient is largely determined by the specific underlying neuromuscular condition and the degree of involvement. although with less aggressive parameters.

Lordosis occurs when the natural arch in the lower back. curves more than normal. with the buttocks more prominent and the stomach seems to be sticking out. Etiology Lordosis is found in all age group. Some might also called lordosis as swayback. upper back.18 26 . the patient may appear swayback. When found in the lumbar spine. It primarily affects the lumbar spine. This can lead to excess pressure on the spine.LORDOSIS A. The spine naturally curves at the neck. and in general an exaggerated posture. Definition Lordosis is defined as an excessive inward curve of the spine. or lumbar region. but can occur in the neck (cervical).17 B. causing pain. and lower back to help absorb shock and support the weight of the head. as well as the body itself.

with Body Mass Index (BMI) more than 24 kg/m 2 might increase the lumbar lordosis angle. there will be extra space between the hand and the back. lordosis can affect people of any age. the exact cause of lordosis in childhood remains unknown. A simplest way to check for lordosis is to ask the patient to lie on his back on a hard surface. 4. and this leads to the change in lumbar angle over time. Spondylolisthesis. D. with little space to spare. Achondroplasia.C. Poor posture. especially central (abdominal) obesity. past progression. Diagnosis Apart from the complaints from patient. The physician should be able to slide his hand under the patient’s back. Kyphosis may force the low back to compensate for the imbalance created by a curve occurring at a higher level of the soine. 2. Some studies showed that a posture affects the angle or vertebra over time. It is hypothetically said that it is due to the prolong tilt of the pelvis by abdominal muscles.19 1. 6. 7. In lordosis. compromising the spine’s structural integrity. This condition occurs when one vertebra slips forward in relation an adjacent one. 5. Other potential causes of lordosis include:17.18. usually in the lumbar spine. It is because some overweight people lean backward to improve balance. Discitis. An inflammation of intervertebral disc space that leads to changing of lumbar curvature. Kyphosis. People who spend more time standing in excessive straight position is said has more lordosis angle than people who are not. However. Obesity. Cause Up till now. Osteoporosis. The physician will want to know when the curvature was first noticed. 17 Other than 27 . A decrease in bone density may affects the strength of the bone. Most researchers agree that obesity. Kyphosis is a condition where there is an excessive outward curvature at the mid-back. and other related symptoms the patient experiences. a thorough physical examination needs to be performed in diagnosing a lordosis. A form of dwarfism that affects the alignment of the vertebra. 3.

ed 4.18  Analgesics and anti-inflammatory medication.18 E.p. 18 Last but not least. 2010. as well as to   enable the patient to build flexibility and increase range of motion. extension. tingling or numbness. surgical intervention is needed. Radiographic examinations that were asked in lordosis are anterior/posterior (AP) and lateral x-ray of lumbosacral. also the range of motion to measure the degree to which a patient can perform movement of flexion. and to see for any asymmetrical appearance. Treatment Treatment for lordosis consists of non-surgical treatment and surgical treatment. Bracing maybe used to control curve progression in adolescents.18 DAFTAR PUSTAKA 1.1118 28 . or non-surgical conservative treatment has failed. editor: Essential of Musculoskeletal care.that. Surgical intervention is considered if the lordotic curve is severe. and MRI may be ordered if the spinal cord has been compromised (or suspected). Side bending AP x-rays are sometimes used to evaluate the flexibility of the spine.  Physical therapy to help build strength in core muscles. lateral bending and spinal rotation. the patient will be asked to bend forward and to the side to see whether the curve is flexible or fixed. Sarwark J. muscle spasm. AAOS. Rosemont.18 A neurological evaluation for the symptoms of pain. Non-surgical conservative treatment may include:17. Reduction of body weight to ideal. radiographic image will be taken to reveal the entire length of spine. when neurologic involvement exists. weakness and bowel/bladder change will be evaluated to see how much lordosis has affects the quality of life of the patient. In severe cases.

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