DORSAL KYPHOSIS

Dr. Laxmikant Dagdia

SPINE ANATOMY
4 CURVES Cervical Thoracic ( 20 to 50 degrees kyphosis ) Lumbar ( 31 to 79 degrees lordosis ) Sacral

SPINE ANATOMY Sagittal balance and plump line

What is KYPHOSIS ??
Greek word : bowed or bent Clinically Increased curvature, causing angulation with posterior convexity and anterior concavity.

What causes KYPHOSIS ??

2 ways it can develop 1) Shortening of anterior column of spine 2) Weakening or lengthening of posterior column.

Etiology of KYPHOSIS
Postural Infectious Traumatic Inflammatory disorders Degenerative Neoplastic Congenital Scheuermann s kyphosis Skeletal dysplasia Neuromuscular

Diagnostic evaluation
Plain radiographs Standing AP and Lateral films of entire spine. Dynamic films : Flexibility of deformity CT, CT Myelogram, MRI To further evaluate bony and soft tissue anatomy comprising deformity.

Diagnostic evaluation cobb s angle measurement

Dorsal KYPHOSIS
Postural thoracic kyphosis Post-infectious kyphosis Scheuermann s kyphosis Osteoporotic fractures Inflammatory disorders like ankylosing spondylitis Neoplastic Congenital Dysplastic

Postural KYPHOSIS
Smooth, flexible curve not more than 60 degrees. In adolscents and young adults. Improvements of posture and extension exercises.

Scheuermann s KYPHOSIS
Common cause worldwide. 2 types 1. Typical : more common, thoracic curve. 2. Atypical : unusual, thoraco-lumbar junction curve, more often seen in athelets and labourers.

Scheuermann s KYPHOSIS
Sorenson s criteria for diagnosis : 1. > 5 degrees of anterior wedging in 3 or more vertebrae at apex of curve. 2. Cobb angle > 45 degrees 3. Irregular vertebral end plates and disc space narrowing in kyphotic zone.

Scheuermann s KYPHOSIS Rx.

Bracing: in skeletally immature patients. Surgery : 1. Skeletally immature : > 75 degrees kyphosis even after brace treatment. 2. Skeletally mature : back pain, >75 degrees kyphosis, unacceptable cosmesis.

Scheuermann s KYPHOSIS: Surgery

Ponte osteotomy : 1.Done in flexible, regional kyphotic deformity. 2.At level of of osteotomy : superior articulating facet of lower vertebra and inferior of upper vertebra removed and osteotomy is closed posteriorly with pedicle screw fixation. 3.C/I : Rigid deformity, acute angular deformity as in TB.

Ponte osteotomy

Post-infectious KYPHOSIS
Post tubercular : most common cause in our country. Paradiscal lesions of TB : Destruction of 1. intervertebral disc. and 2. Adjacent vertebral bodies Cause shortening of anterior column of spine leading to KYPHOSIS.

KYPHOSIS in Potts spine

Without neurological deficit in active disease: Unless deformity is progressive while on ATT conservative treatment continued.

KYPHOSIS in Potts spine

With neurological deficit
Improving with ATT Continue conservative Rx. Long term follow up. Not improving or worsening Decompression and/or fusion

KYPHOSIS in Potts spine in children

Indications for fusion in children with healed or active disease. Rajasekaran (2007) : radiographic signs to assess spine at RISK 1. Separation of facet joints 2. Posterior retropulsion of diseased vertebrae 3. Toppling sign 4. Lateral transalation of vertebaral column.

1. Separation of facet joints. 2. Retropulsion of diseased vertebrae 3.Lateral translation of vertebral column 4. Toppling sign .

Post-tubercular kyphosis with spine at RISK signs

Intraoperative heartshell application.

Post tubercular kyphosis in healed disease

SURGERY
Posterior spinal fusion Anterior transposition of cord Panvertebral fusion

INDICATION
Symptomatic mechanical instability in a healed disease. Neural complications due to severe kyphosis Prevention of severe kyphosis in children with extensive dorsal lesions. Recurrence of disease or neural complication. Severe deformity >70 degrees in healed disease.

Debridement and/or decompression and/or fusion Closing-opening wedge osteotomy

Closing opening wedge osteotomy

Closing opening wedge osteotomy

A: Indications : rigid kyphotic deformity, > 70 degrees as in 1. Potts spine 2. Congenital kyphosis 3. Post laminectomy kyphosis. B: C/I : 1. Deformity >120 degrees 2. With neurological deficit.

Osteoporotic fractures
Each standard deviation decrease in BMD = Twofold increase in spine fractures. Conservative management : Analgesics, bed rest and medical treatment of underlying cause.

Osteoporotic fractures
Indications for aggressive line of treatment: Continued progressive deformity Neurologic deterioration Pain Open fracture repair difficult : 1. Poor bone quality 2. Compromised medical status of patient.

Minimally invasive surgeries for Osteoporotic fractures

Vertebroplasty : Percutaneous injection of polymethylmethacrylate( PMMA ) into a fractured vertebral body. Kyphoplasty : insertion of balloon that is inflated in vertebral body before injection of PMMA.

Vertebroplasty placement of trocar and injection of PMMA

Kyphoplasty: balloon inflation before injection of PMMA

Congenital kyphosis
Type 1 : Failure of vertebral body formation 1. Posterolateral quadrant vertebrae 2. Butterfly ( sagittal cleft ) vertebrae

Congenital kyphosis
3. Posterior hemivertebrae 4. Anterior wedged vertebrae

Congenital kyphosis
Type 2 : Failure of segmentation

Congenital kyphosis
Type 3 : Combination of 1 and 2.

Ankylosing spondylitis
Seronegative autoimmune disorder Sometimes causes rigid kyphotic deformity by involving multiple consetive vertebrae.

Ankylosing spondylitis lumbar osteotomy

THANK YOU ALL !!!