Spinal Conditions

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Introduction
• The spine is the framework for our posture and movement.
• It supports our cranium, extremities, and spinal cord; allows for trunk
flexibility ; act as a shock absorber; and provides structural support
for normal chest and respiratory development.
• Orthopaedic concerns arise when spinal alignment is altered by
congenital or progressive changes, producing scoliosis, kyphosis, or
lordosis.
• Each one or combination of these conditions , if left untreated may
affect a child’s pulmonary function, psychosocial wellbeing, potential
for back pain and life expectancy.
Scoliosis:
• Scoliosis is the abnormal lateral curvature of the spine.
• DETECTION: Detection of scoliosis is primarily by identification of trunk and shoulder, or
pelvic asymmetries.
• EXAMINATION:
• An examination begins with a complete patient history.
• Physical examination:
• Assesment of spinal alignment by forward bending test
• General alignment
• Shoulder and pelvic symmetry
• Trunk compensation using a plumb line
• Leg length measurement.
• Radiographs: (lateral and P/A view)
• used to determine location, type and magnitude of curve, skeletal
age.
• Skeletal maturity: Risser sign
• Spinal curvature: cobb method

• A scoliosis curve of
• 10 to 15 degrees: do not require any treatment
• 20 to 40 degrees: back brace
• 40 or 50 degrees or more: surgery
Terminology
• Spinal deformities are classified according to etiology, location, magnitude and
direction.
• Curvatures maybe idiopathic, neuromuscular, or congenital and may further be
classified by:
• AREA of spine: in which the apex of the curve is located
 cervical curve: between C1 and C6
 cervico thoracic curve: between C7 and T1
 thoracic curve : between T2 and T11
 thoracolumbar curve: between T12 and L1
 lumbar curve: between L2 and L4
 lumbosacral curve: between L5 and S1.
• MAGNITUDE: Cobb method

• DIRECTION: Right or Left by side of the convexity of deformity.

• TWO MAJOR types of curvatures:

structural and non structural
Idiopathic Scoliosis:
• Lateral curvature of the spine of unknown cause and most common form
of scoliosis in children.
• 1: Infantile idiopathic scoliosis:
• In children younger than age 3, usually manifesting shortly after birth

• Occur more frequently in male infants and majority of the curves are left.

• 80 to 90% of curves spontaneously resolve , but many of the remainder

cases progress throughout childhood , resulting in severe deformity.
• Juvenile Idiopathic Scoliosis:
• Develops between age 3 and 9 years of age.
• Most common curve is right thoracic , occurring in males and females
with equal frequency.
• Recognised most often around 6 years of age.
• Adolescent Idiopathic Scoliosis:
• Categorizes curves at or around the onset of puberty and accounts for
approximately 80% of all cases of idiopathic scoliosis.
• A number of theories have been proposed that attempts to explain
the mechanics of vertebral coloumn further decompensation of spine
as seen in idiopathic scoliosis.
• These causes include:
• Insufficiency of the vertebral ligaments.
• Asymmetric weakness of paraspinal musculature.
• Unequal distribution of type 1 and type 2 muscle fibres.
• Collagen abnormalities.
STRUCTURAL CHANGES:
• vary with degree of scoliosis , affect anatomy and physiology of spine, with the
greatest change at the apex of the curve.
• Compression and distraction forces act on the growing spine to produce wedge shaped
vertebrae.
• Changes occurring on the concave side of the curvature include compression and
degenerative changes of intervertebral discs and shortening of muscles and ligaments.
• Changes in thoracic spine directly affect the rib cage.
• The translatory shift of the spine causes an asymmetrically divided thorax, producing
decreased pulmonary capacity on the convex side and increased pulmonary capacity
on the concave side.
• Structural changes cause cosmetic deformity, that in turn, affect appearance and
psychosocial well being.
NATURAL HISTORY:
• A progressive curve is defined by
• A sustained increase of 5degree or more on two consecutive examinations
occurring at 4 to 6 month intervals.
• Following factors influence the progression in skeletally immature patients:
• 1: The younger the patient at diagnosis, the greater the risk of progression.
• 2: The lower the riser sign , greater the risk of progression
• 3: Curves with greater magnitude are at greater risk to progress.
• 4: Greater risk of progression is present when curves develop before
menarche.
CONGENITAL SCOLIOSIS
• Caused by anomalous vertebral development.
• Failure of vertebral segmentation or vertebral formation.
• Both pathological processes are frequently seen in the same spine
• Occur either at the same or different levels.
• Location of the pathologic process on the vertebra (ant, post, lat or
combination) determines the congenital deformity.
• LATERAL DEFORMITY: congenital scoliosis
• ANT-LAT DEFORMITY: congenital kyphoscoliosis
• POST-LAT DEFORMITY: congenital lordoscoliosis.
• DEFECT OF SEGMENTATION:
• Is seen when adjacent vertebra donot completely separate from one
another,
• producing unsegmented bar ,
• with no growth or disk plate between adjacent vertebra.
• A lateral one sided defect of segmentation produce severe
progressive congenital scoliosis.
• DEFECTS OF FORMATION: maybe partial or complete.
• An anterior failure of formation of vertebral body: kyphosis
• A partial unilateral defect of formation of vertebral body: wedge shaped
hemi vertebra, only one side with growth potential.
• A nonsegmented hemivertebra : completely fused to the adjacent
proximal and distal vertebrae.
• A semi segmented hemivertebra: fused to only one adjacent vertebra and
separated from other by normal end plate and disk.
• A segmented hemivertebra: separated from both proximal and distal
vertebra by a normal end plate and disk.
Interventions for Idiopathic and Congenital
scoliosis
• NON SURGICAL INTERVENTIONS:
• EXERCISES: trunk and pelvic strength and flexibility.
• Postural exercises (trunk extensor control, abdominal strengthening,
gluteal strengthening),
• stretching of pectorals and lower extremities,
• respiratory exercises to increase chest capacity and maximize volume.
• Rehabilitative exercise program (6 hrs/day for a minimum of 4-6 weeks )
has the potential to reduce the incidence of progression in children
with idiopathic scoliosis.
• ELECTRICAL STIMULATION:
• Rarely used as an intervention for idiopathic scoliosis.
• Electrical stimulation was used to produce sufficient stimulation of muscles
on the convex side of the curve to alter the direction of deformity.
• Decrease the pressure on the concave side of the curve.
• ORTHOTIC MANAGEMENT:
• The indication for orthotic use depends on curve type, magnitude, and
location.
• Orthoses are typically prescribed for children with idiopathic scoliosis who
are skeletal immature.
NEUROMUSCULAR SCOLIOSIS
• The term neuromuscular scoliosis and myopathic scoliosis describe
curves that are due to neurologic or muscular disorders.
• Curves maybe secondary to pelvic obliquity ,
• Unilateral or asymmetric spasticity of trunk musculature,
• Athetosis,
• Or asymmetric movement patterns.
• Often a long C type curve characterizes a neuromuscular curvature
• But as compensatory curves becomes structural , the pattern may
change to an S type curve.
• INTERVENTION:
• These children often have multiple disabilities which are best
addressed by team approach of
• Physical therapist
• Occupational therapist
• Physician
• Equipment vendor
• Orthotist.
KYPHOSIS
• Abnormal posterior convexity of a segment of the spine.
• May occur as a result of :
• Trauma
• Congenital conditions
• Scheuermann’s disease
• Secondary to previous treatment of spinal tumors with laminectomy.
CONGENITAL KYPHOSIS
• It results when:
• Anterior part of the vertebra is aplastic or hypoplastic.
• Posterior part of the vertebra form normally.
• Congenital kyphoscoliosis or lordoscoliosis is the result when a combination of
defective segmentation occurs at more than one location.
• NATURAL HISTORY:
• Progression
• Cosmetic deformity
• Back pain
• Neurologic deficit.
• An anterior unsegmented bar at the thoracolumbar junction produces
mild to moderate deformities but no reported paraplegia.
• Paraplegia is frequently noted with a progressive congenital kyphosis
located in the upper thoracic spine.
• Treatment is surgery to prevent further progression.
SCHEUERMANN’S DISEASE:
• Scheuermann's disease is a  skeletal disorder of childhood.
• Usually ascribed to poor posture.
• Diagnosis is made by these radiographic criteria:
• 1: irregular vertebral end plates
• 2: narrowing of the intervertebral disk space
• 3: anterior wedging of 5 degree or greater of one or more vertebra
• 4: kyphosis greater than 40 degree that is uncorrected on active
hyperextension.
• Clinical findings include:
• Tight pectorals and hamstrings.
• An increased thoracic kyphosis with a compensatory increased lumbar lordosis
and forward head posture are seen.
• Associated scoliosis is present in 30% to 40% of children with Scheuermann’s
disease.
• Anterior longitudinal ligament is thickened and taut, as in other kyphosis.
• INTERVENTIONS:
• Exercise, orthotic management, and surgical management.
• Orthotic treatment is used when the kyphosis is greater than 50 to 60 degree.
• POSTURAL ROUNDBACK:
• Kyphosis of roundback is not fixed and vertebra show no endplate irregularity.
• Exercise alone is the treatment of choice.
• If kyphosis progress to more than 60 degree it maybe treated with Milwaukee
brace.
• KYPHOSIS AND MYELOMENINGOCELE:
• Spinal deformities are common in children with myelomeningocele.
• A congenital lumbar kyphosis, involving the portion of spine from
thoracolumbar junction to sacrum, is unique to children with
myelomeningocele.
LORDOSIS:
• An anterior convexity (or a posterior concavity)of a segment of spine.
• Congenital lordosis is the result of bilateral posterior failure of segmentation.
• A lordosis may develop in the thoracic vertebra to compensate for an
increased lumbar kyphosis.
• Assesment includes :
• Testing of lower extremity ROM
• Spinal flexibility
• Trunk and lower extremity strength
• Posture and gait.
SPONDYLOLISTHESIS:
• Forward translator displacement of one vertebra on another .
• 5 types of spondylosis and spondylolisthesis have been classified by
Wiltse and associates as:
• Dyplastic
• Isthmic
• Degenerative
• Traumatic
• Pathologic
• Dyplastic and isthmic types are most common in pediatric population.
• Degree of severity:
• Grade 1: less than 25 % slippage
• Grade 2: 25% to 50% slippage
• Grade 3: 50% to 75% slippage
• Grade 4: greater than 75% slippage.
• CLINICAL SYMPTOMS:
• Low back pain relieved by rest
• Sciatic type pain
• Local tenderness
• Hamstring spasm or tighteness
• Torso shortening.