SPINAL DEFORMITIES

‘Spinal deformity’ refers to the loss of normal

alignment of a straight spine in the coronal plane
or the cervical lordosis, thoracic kyphosis and lumbar
lordosis in the sagittal plane.
It may be due to
• a congenital
• or developmental malformation.
The latter may be
• Idiopathic
• associated with neuromuscular conditions
• or the consequence of degenerative processes.
 Scoliosis
Scoliosis is a complex rotational deformity which may
manifest with a thoracic or lumbar prominence, shoulder
imbalance, coronal shift and infrequently pain.
Two broad types of deformity are defined:
• Postural (Secondary or Compensatory)
• structural
 Postural scoliosis
In postural scoliosis the deformity is secondary, or
compensatory, to some condition outside the spine,
such as a short leg, or pelvic tilt due to contracture
of the hip. When the patient sits (thereby cancelling
leg length asymmetry), the curve disappears. Local
muscle spasm associated with a prolapsed lumbar disc
may cause a skew back; although sometimes called
‘sciatic scoliosis’ this, too, is a spurious deformity.
The scoliosis is usually mild and has minimal rotation
 Structural scoliosis
In structural scoliosis there is a non-correctable deformity of the affected
spinal segment, an essential component of which is vertebral rotation. The
spinous processes point towards the concavity of the curve and the
transverse processes on the convexity rotate posteriorly. In the thoracic
region the ribs on the convex side stand out prominently, producing the
rib hump, which is a characteristic part of the overall deformity.
The deformity tends to progress throughout the growth period. With very
severe curves, chest deformity is marked and cardiopulmonary function is
usually affected.
 Types of structural scoliosis are :
• idiopathic scoliosis with no obvious cause but
appears to have a genetic basis and a predictable
course.
• congenital - failure of vertebral formation or
segmentation
• neuromuscular group ranging from cerebral palsy,
spinal muscular atrophy to muscle dystrophies, and
a miscellaneous group of connective-tissue
disorders.
 Clinical features
Deformity is usually the presenting symptom: an obvious
skew back or rib hump in thoracic curves, and asymmetrical
prominence of one hip or flank crease in thoracolumbar curves.
Balanced curves sometimes pass unnoticed until quite severe.
Pain is a rare complaint and should alert the clinician to the
possibility of an unusual underlying cause and the need for
investigation.
Treatment
The aims of treatment are: (1) to prevent a mild deformity
from becoming severe; and (2) to correct an existing deformity that is
unacceptable to the patient. A period of preliminary observation may be
needed before deciding between conservative and operative treatment.
NON-OPERATIVE TREATMENT
If the patient is approaching skeletal maturity and the deformity is acceptable (which
usually means it is less than 30 degrees and well balanced), treatment is
probably unnecessary unless sequential X-rays show definitive evidence of
progression.
Exercises are often prescribed; they have no effect on the curve but they do maintain
muscle tone and may inspire confidence in a favorable outcome. Bracing has been
used for many years in the treatment of progressive scoliotic curves between 20 and
30 degrees A variety of braces are available, some cast and others prefabricated. They
generally include the thoracic and lumbar spine to the pelvis with pads to push the
spine into a more normal alignment. Compliance determines success and they need to
be worn for more than 20 hours a day
 OPERATIVE TREATMENT
Surgery is indicated for curves that are predicted
to be more than 50 degrees at maturity in growing
patients or those with established large, cosmetically
unacceptable curves. The objectives are: (1) to halt
progression of the deformity; (2) to restore the normal
spinal contours with instrumentation; and (3) to
arthrodese the entire primary curve by bone grafting.
In posterior instrumentation the spine is instrumented
segmentally from posterior with pedicle
screws and hooks which are connected to pre-contoured
rods to correct the deformity via the mobile
discs .Older sub-laminar wiring techniques
may still be used if pedicles are too small for
screws or to reduce cost in long neuromuscular scoliosis.
If the deformity is rigid, it may require resection
of the facets (ponte osteotomies) and even concave rib
resections to allow correction.
Anterior surgery is another option where the discs
are resected and screws placed into the vertebral bodies,
straightened with the addition of the rod. The
advantage may be a shorter construct but increased
morbidity of a transthoracic approach. It is useful in
thoracolumbar curves where excellent rotational correction
can be induced with the disc release.
 WARNING: During correction, spinal cord injury may occur due to cord traction
with column lengthening. Spinal cord electrophysiological monitoring should be
performed, ideally both somatosensory and motor-evoked potential monitoring, during
spinal correction. If these facilities are not available or there is an electrophysiological
alert, the ‘wake-up test’ is used. Anesthesia is reduced to bring the patient to a semi-
awake state and he or she is then instructed to move their feet. If there are signs of cord
compromise, the instrumentation is relaxed or removed and reapplied with a lesser
degree of correction.

In severe, rigid curves, even the best of the instrumentation systems cannot completely
eliminate the rib hump – and it is often this that troubles the patient most of all. If the
deformity is marked, it can be reduced significantly by performing a costoplasty, where
short sections of rib are excised at multiple levels on the rib hump (convex) side, close to
the vertebral articulation.
 Complications of surgery
Neurological compromise With modern techniques the
incidence of permanent paralysis has been reduced to less than
1%. From the patient’s point of view this is small comfort. Every
effort should be made to provide adequate safeguards.
Pseudarthrosis Incomplete fusion occurs in about2% of cases
and may require further operation and grafting.
Implant failure Implants may dislodge and rods
fracture especially in delayed/non-union.
 KYPHOSIS
The term ‘kyphosis’ is used to describe both the normal (gentle
rounding of the thoracic spine) and the abnormal (excessive
thoracic curvature or straightening out of the cervical or lumbar
lordotic curves).
Kyphos, or gibbus - is a sharp posterior angulation due to
localized collapse or wedging of one or more vertebrae.
This may be result of – A congenital defect
A fracture
Spinal tuberculosis
 SURGICAL TREATMENT
Surgery for abnormal kyphosis is usually the last treatment
option tried; non-surgical treatments, such as physical therapy,
Bracing, should be tried first. If the pain and other symptoms
don't lessen after several months of non-surgical treatments, the
doctor may suggest surgery

Surgery for abnormal kyphosis has several main goals:

- Reduce Deformity
- Reduce pain and any neurological Symptoms
- Prevent Curve From Getting Worse
Criteria taken into consideration for abnormal
kyphosis surgery are:
- Curve severity: Curve severity is dependent on where  spine
has the hyperkyphotic curve. In the mid-back (thoracic spine),
curves greater than 80° are considered severe; in the mid-back
to low back region (thoracolumbar), curves greater than 60°-
70° are severe.
- Curve Progression: If the curve is getting worse rapidly,
despite non-surgical treatments
- Balance: If the curve is making it difficult to get through your
daily life because you're off balance.
- Neurological Symptoms: Kyphosis can affect the spinal nerves
because changes in the spine—such as vertebral fractures—
can cause pinched nerves. Patient may have weakness,
numbness, or tingling, and in severe cases, when surgery is
recommended,
 OSTEOTOMY

During an osteotomy, bone is cut to correct angular deformities.

The bone ends are realigned and allowed to heal. Spinal
instrumentation and fusion may be combined with an osteotomy
to stabilize the spine during healing .
 SPINAL INSTRUMENTATION AND FUSION

Once the spine has been realigned through an osteotomy, the

surgeon will need to stabilize it to help the spine heal in the new
position. To do this, the surgeon creates an environment where
the bones in spine will fuse together over time (usually over
several months or longer). The surgeon
uses a bone graft (usually using donor
bone as well) or a biological substance
(which will stimulate bone growth).
The fusion will stop movement between
the vertebrae, providing long-term
stability.
 BALLOON KYPHOPLASTY
Balloon kyphoplasty may be considered a treatment option in
select patients with compression fracture. Kyphoplasty is a
minimally invasive treatment, meaning that it's performed
through very small incisions. Minimally invasive surgeries also
have a shorter recovery time than traditional surgeries. In
balloon kyphoplasty, a special orthopaedic balloon is inserted
into your compressed (collapsed) vertebra. It's inflated in an
attempt to return the vertebra to the correct height and
position. The balloon creates a void—an empty space—in your
vertebra, and the void is filled with a surgical cement, which
helps to stabilize the fracture.
 SURGICAL RISKS

• Injury to spinal nerves

• Non-Healing of the bony fusion (pseudoarthrosis)
• Failure to improve
• Instrumentation breakage/failure
• Infection and/or bone graft site pain.

RECOVERY

• Pain and discomfort after surgery

• Patient Controlled Analgesia is used to control pain
• Physical Therapy- To Gain strength, flexibility and range of
motion.
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