When discussing the natural history of the disease, you tell the family they should expect: Radiographs of her spine show an apex left lumbar curve measuring 32 degrees and an apex right thoracic curve measuring 28 degrees. Discontinuation of bracing as she has reached skeletal maturity. (OBQ13.61) Neuromuscular, develop-mental, and tumor-associated scoliosis together constitute the remaining 10% (8). Team Orthobullets 4 Pediatrics - Spinal Muscular Atrophy ; Listen Now 10:46 min. On an x-ray with a front or rear view of the body, the spine of a person with scoliosis looks more like an \"S\" or a \"C\" than a straight line. A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. Which of the following methods of determining skeletal maturity correlates most closely with the curve acceleration phase for children with idiopathic scoliosis? (SAE07PE.98) Physical exam shows absent abdominal reflexes in the upper and lower quadrants on the left side, but present on the right. The exact mechanisms of the condition are not well understood. 113 plays. Tested Concept, Observation and referral to an endocrinologist, (OBQ12.178) consultation with a pain management specialist. Scoliosis, 2008. Spine (Phila Pa 1976), 2010 3. The cobb angle is 38 degrees. MB BULLETS Step 1 For 1st and 2nd Year Med Students. In some instances, bracing 10/21/2019. She denies pain. PNF, Proprioceptive neuromuscular facilitation is a healing philosophy based on the assumption that every man, even those with problems, have unused psychophysical possibilities. Correction of severe pelvic obliquity using maximum-width segmental sacropelvic screw fixation: an analysis of 20 neuromuscular scoliosis patients. 10/21/2019. MB BULLETS Step 1 For 1st and 2nd Year Med Students. difficulty with vaginal child birth in the future. 2015 Apr-May. 20 ABOS Breakdown ABOS 2020 Spine ... • Neuromuscular disease 1.0% 1.5 Neuromuscular Scoliosis 6.0% 9.0 • Thromboembolus 2.0% 3.0 Thromboembolism The orthosis shown in Figure A is indicated for the treatment of the spinal deformity shown in which of the following radiographs? an alternative method is to dissect from midline and enter the medial wall of the iliac crest, expose the outer table to visualize trajectory (from PSIS to sciatic notch), use a rongeur just lateral to the PSIS to expose cancellous bone, use a lenke probe/awl to create a tract between the inner and outer wall of the iliac wing aiming toward the anterior inferior iliac spine (AIIS) taking care to avoid the sciatic notch, probe tract with ball trip probe to confirm osseous channel and measure length of tract, place screw in tract and confirm position with c arm fluoroscopy, create channel from the PSIS to the lateral ilium by using progressively larger probes, this channel should pass just superior to the sciatic notch, once the channel is made, insert a rod (5.5 mm in smaller children) to a depth of 6-7 cm, Verify bony walls intact and measure depth of channel, probe the channel to ensure that the bony walls are intact and measure the depth of the channel for later Galveston Rod Placement, use bone wax to plug the hole at the PSIS to prevent blood from oozing before final rod placement, remove the facets with a rongeur, osteotome, burr or bone scalpel, start at the L5-S1 articulation and proceed cephalad to the level below the planned upper instrumented vertebrae, remove a window of ligamentum flavum at each interspinous region if planning wire passage, use gelfoam soaked in thrombin when needed to control local bleeding, if needed for additional deformity correction a ponte osteotomy can be performed by removing the facet in its entirety with a combination of a Kerrison rongeur and burr, Identify the pedicle starting point and use a high speed cortical burr to mark starting point and penetrate cortical surface, Insert lenke pedicle probe into the pedicle with the tip pointing laterally at the identified starting point and advance to 20mm or alternatively a 2.0 mm drill bit can be used, Probe the tract using a flexible sounding probe (ball tip probe) to palpate the superior, inferior, medial and lateral walls and the endpoint (floor), If no breeches are appreciated face Lenke probe medially and advance to anterior cortex or alternatively a 3.2 mm drill bit can be used, Place the pedicle screw slowly in the orientation of the tract that was created, Stimulate screws: if less than 6-8mA reevaluate screw position, Confirm position of screws with AP and lateral C-arm fluoroscopy, For additional details on pedicle screw placement see technique for idiopathic scoliosis, contour 16 gauge double wires to allow sublaminar passage, wire should be bent with a radius of curvature that approximates the width of the lamina, keep gentle pressure anteriorly to make sure you are not to deep and inadvertently damaging the cord, conversely do not push so hard on the undersurface of the lamina that the tip is caught and the wire is levered into the spinal cord, pull tip through until ends are of similar lengths, then can cut to separate the double wire, separate the wires placing one wire on each side of the spine, it is important to roll rather than push when placing sublaminar wires, add 5-10cm depending upon size and flexibility of the curve, If using SAI screws, the rod will need a sharp bend at lumbosacral junction (around 70 degrees), use hand benders to bend the rod at 90 degrees at the marked location, place the short end of the rod in the slot at the end of the Galveston Rod benders, have an assistant hold the long end of the rod parallel to the operating room table top, this should be held vertical to this plane, place a rod bender on the short end of the rod to bend the end 90 degrees to a position perpendicular to the operating room table, bend the kyphosis into the upper rod for appropriate sagittal plane alignment, bend the second rod so that it mirrors the shape of the first rod, insert the rod on either side of the scoliosis, Spread the sublaminar wire apart usually with the distal wire limb passing laterally, place a surgical towel over the wires of the second side to prevent confusion, after the wires have been spread insert the initial Galveston rod into the iliac wing and tamp into place at the PSIS, Prepare the rods for insertion add the depth of the iliac crest channel and the offset distance from the PSIS to the midpoint of the L5 lamina make a mark at the distance from the end of the straight rod, After placement examine the lateral iliac wing to ensure that the rod didn't penetrate laterally during insertion, It is better to use a softer/more flexible rod or do additional contouring for less correction than to pull out anchors, After rod is seated additional bending with in situ or L-benders can be performed to optimize correction, If using SAI screws can align rods with SAI screws and pedicle screws directly, If using iliac screws then will need a connector to attach to rods, can consider connecting the concave and convex rods via a connector for added rigidity, especially with weak bone, use serial reducers to load share on multiple fixation points, The T square of Tolo can be very helpful in intraoperatively assessing that pelvic obliquity is improved and sitting balance has been achieved, tighten the sublaminar wires starting at L5, sequentially tighten the wires on the side to L1 or L2, place downward pressure with rod pusher on the rod as a counterforce to the wire tightening to minimize the chance of wire pull through, contour the upper end of the rod in the kyphotic position to minimize the risk of pullout of the upper Implants, hold manually in place with a rod pusher while the 2 most cephalad sublaminar wires are tightened, Insert the concave side rod into the upper spinal implants, Hold the rod into place while the upper two sublaminar wires on the side are tightened, tighten the remaining sublaminar wires on the concave side, once all the have been tightened cut the twisted wire at a level that leaves them about 1 to 1.5 cm in length, consider placement of one additional cross link to stabilize the upper end of the instrumentation at the midthoracic level, bend the wire ends and tamp down to prevent dorsal protrusion, Sublaminar wires or bands can also be used to supplement screws especially with weak bone to avoid screw pullout, The wires or bands can be used to do provisional reduction and then rod can be seated in screws, decorticate the exposed bony areas through the region of intended fusion with rongeurs and a power burr, irrigate spine with saline (author's preference is to use a 3L bag of irrigation with castile soap), author's preference is to add vancomycin powder- mixing half of it with the bone graft and sprinkling half of it above the fascia once closed, place hemovac drain under fascia if there is enough bleeding/multiple osteotomies to raise concern for hematoma formation, need water tight closure and need to decrease dead space for hematoma, many of these children have conditions associated with slow or poor wound healing, if risk of dehiscence is high, consider reinforcing with use of additional nonabsorbable suture (3-0 nylon), Author's preference is to use waterproof layer at base to prevent soiling reaching the incision in patients who are developmentally delayed or have impaired sensation/inability to communicate when they have soiled the dressing, changes dressing when soiled or based on attending preference, review postoperative radiographs and identifies mal-positioned pedicle screws, loss of fixation and overall correction. After the history and physical examination, the next step in evaluating congenital scoliosis is obtaining x-rays. The curvature tends to be most severe in children who do not walk. Which statement best represents the indicated course of action in this patient? (Curve progression and trunk imbalances are more severe in patients who are not able to walk). We reviewed the recent literature regarding evaluation and management of NMS patients and explored areas where further research is needed. Tested Concept, (SBQ09SP.17) MB BULLETS Step 1 For 1st and 2nd Year Med Students. The 'Risser sign' is one of the most commonly used markers for skeletal maturation and growth potential in patients with adolescent idiopathic scoliosis. Neuromuscular scoliosis is a sideways curvature of the spine caused by poor muscle control, neurological problems and other issues. Neurologic examination is normal. Pelvic fixation with Sacral Alar Iliac (SAI) Screws 2. She occasionally takes acetaminophen, but the pain does not limit sport activities. Vertebral Column Resection For Severe Spinal Deformity A vertebral column resection is a procedure reserved for the most severe spinal deformities. decreased pulmonary function in the future, to undergo an MRI to rule out any underlying neurologic pathology, as this is an abnormal curve, an increased risk of chronic back pain over her lifetime, this curve magnitude has the highest curve progression rate without operative intervention, (OBQ04.144) teardrop view, remove pedicle probe/awl and probe tract with ball tip to confirm osseous channel and measure tract, for adults a minimum diameter of 8.5mm is typical and this may be appropriate for older teenagers, for younger children a smaller diameter may be necessary, place screw and confirm position with AP and teardrop fluoroscopic images, if orientation of pelvis/imaging is unclear, one can dissect along outer table, then, place finger in depression of sciatic notch to confirm direction of tract, make a separate fascial incision over the PSIS. A girl who is Risser 4, Sanders 7, with a 30 degree curve. Neuromuscular Scoliosis Scoliosis is a condition that causes the spine to curve sideways. teardrop view, Advance probe towards anterior inferior iliac spine, aim for just above the hip joint, but take care not to enter the hip joint, confirm position of probe with c-arm fluoroscopy in both orthogonal imaging perpendicular to the tract of the probe and parallel to the probe, i.e. She is two years post-menarcheal. Everyone's spine has subtle natural curves. Tested Concept. A PA standing radiograph is shown in Figure A. Tested Concept. Continue nocturnal bracing until skeletal maturity. Advance probe towards anterior inferior iliac spine aim for just above the hip joint, but take care not to enter the hip joint confirm position of probe with c-arm fluoroscopy in both orthogonal imaging perpendicular to the tract of the probe and parallel to the probe, i.e. 20. Instead of a straight line down the middle of the back, a child with neuromuscular scoliosis has a spine that looks more like a letter “C.” Copyright © 2021 Lineage Medical, Inc. All rights reserved. ORTHO BULLETS Orthopaedic Surgeons & Providers Karlin, The relationship between preoperative nutritional status and complications after an operation for scoliosis in patients who have cerebral palsy. A 12-year-old female is referred to the office by a community orthopaedic surgeon concerned that her shoulders appear to be at different heights. Tested Concept, (OBQ11.49) (SAE07PE.25) J Pediatr Orthop. Jevsevar, D.S. Tested Concept, Curve magnitude of more than 20 degrees at menarche, Curve magnitude of more than 30 degrees at the peak height velocity, Curve magnitude of more than 30 degrees at skeletal age 12 years, Curve magnitude of more than 30 degrees at Risser grade 2, Curve flexibility of less than 50% at Risser grade 2, (OBQ07.79) At age 15, after 3 years of bracing, a repeat posteroanterior radiograph is obtained, now revealing a right thoracic curve measuring 11 degrees and the left lumbar curve measuring 19 degree, and Risser 4. Compared with idiopathic scoliosis, neuromuscular scoliosis is much more likely to produce curves that progress, and continue progressing into adulthood. A standing PA and lateral radiograph is shown in Figures A and B. osteoarthritis orthobullets + osteoarthritis orthobullets 12 Dec 2020 Cervical spondylosis is a common degenerative condition of the cervical spine which is caused by age-related changes in the cushion ... osteoarthritis orthobullets Expert panel. Mullender, M., et al., A Dutch guideline for the treatment of scoliosis in neuromuscular disorders. 35 (3):258-65. . Tested Concept, Thoracic curve coronal correction of > 40%, Thoracolumbar/lumbar curve coronal correction > 50%, Failure to maintain lumbar lordosis of > 45 degrees, (OBQ06.35) A 12-year-old girl who is 3 months postmenarchal undergoes full-time brace treatment for scoliosis. 4.8 (8) See More See Less. Examination reveals a mild right rib prominence during forward bending. The lumbar curve from T12 to L5 measures 36 degrees, and the thoracic curve from T3 … On Adams forward bending, she measures 6 degrees. Defined as idiopathic scoliosis in children, incidence of 3% for curves between 10 to 20°, 1:1 male to female ratio for small curves, cartilaginous plate that forms between the centrum and posterior neural arches, increased incidence of acute and chronic pain in adults if left untreated, curves > 90° are associated with cardiopulmonary dysfunction, early death, pain, and decreased self image, risk factors for progression (at presentation), > 25° before skeletal maturity will continue to progress, > 50° thoracic curve will progress 1-2° / year, > 40° lumbar curve will progress 1-2° / year, Risser 0 covers the first 2/3rd of the pubertal growth spurt, correlates with the greatest velocity of skeletal linear growth, is the best predictor of curve progression, if curve is >30° before peak height velocity there is a strong likelihood of the need for surgery, thoracic more likely to progress than lumber, double curves more likely to progress than single curves, five part classification to describe thoracic curve patterns and help guide surgeons implanting Harrington instrumentation, link to King-Moe classification (not testable), more comprehensive classification based on PA, lateral, and supine bending films, helps to decide upon which curves need to be included within the fusion construct, link to Lenke classification (not testable), patients often referred from school screening where a, axial plane deformity indicates structural curve, can eliminate leg length inequality as cause of scoliosis, other important findings on physical exam, rib rotational deformity (rib prominence), can suggest neural axis abnormalities and warrant a MRI, coronal balance is determined by alignment of, sagittal balance is based on C7 plumb from center of C7 to the posterior-superior corner of S1, between lines drawn vertically from lumbosacral facet joints, most proximal vertebrae that is most closely bisected by central sacral vertical line, rotationally neutral (spinous process equal distance to pedicles on PA xray), end vertebra is defined as the vertebra that is most tilted from the horizontal apical vertebra, the apical vertebraeis the disk or vertebra deviated farthest from the center of the vertebral column, best predictor of postoperative shoulder balance, should extend from posterior fossa to conus, purpose is to rule out intraspinal anomalies, left thoracic curve, short angular curve, apical kyphosis, a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation, Based on skeletal maturity of patient, magnitude of deformity, and curve progression, obtain serial radiographs to monitor for progression, only effective for flexible deformity in skeletally immature patient (Risser 0, 1, 2), goal is to stop progression, not to correct deformity, 50% reduction in need for surgery with compliant brace wear of at least 13 hours a day, poor prognosis with brace treatment associated with, noncompliant (effectiveness is dose related), can be used for all types of idiopathic scoliosis, remains gold standard for thoracic and double major curves (most cases), best for thoracolumbar and lumbar cases with a normal sagittal profile, (Risser grade 0, girls <10 yrs, boys < 13 yrs), recommended for 16-23 hours/day until skeletal maturity or surgical intervention deemed necessary (actual wear minimum 12 hours required to slow progression), Milwaukee brace (cervicothoracolumbosacral orthosis), Charleston Bending brace is a curved night brace, 6° or more curve progression at orthotic discontinuation (skeletal maturity), absolute progression to >45° either before or at skeletal maturity, or discontinuation in favor of surgery, <1cm change in height over 2 visits 6 months apart, fusion should include enough levels to adequately maintain sagittal and coronal balance while being as minimal as safely possible to preserve motion, typical fusion from proximal end vertebra to one or two levels cephalad to the stable vertebra, double and triple major curves fuse to the distal end vertebra, recommends one level above and two levels below the end vertebrae if these levels fall wilthin the stable zone, recommends fusion to the neutral vertebrae, recommends including all major curves in the fusion and minor curves that are not flexible or are kyphotic. tal scoliosis, which includes scoliosis caused by structural abnormalities of bone and neural tis-sues, is the second most common type, account-ing for 10% of cases. Continue full-time bracing until skeletal maturity. But some people have different curves, side-to-side spinal curves that also twist the spine. Tested Concept, Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, Pathogenesis of AIS: Braces & Monitoring: You Can Do It! ORTHO BULLETS Orthopaedic Surgeons & Providers Galveston Rod Preparation, Placement of wires, hooks or pedicle screws. Tested Concept, (OBQ12.70) With Adam's forward bending, she is noted to have a significant right thoracic rib prominence. After a complete history and physical, you order PA thoracolumbar radiograph, which is seen in figure A. Awwad W, Al-Ahaideb A, Jiang L, Algarni AD, Ouellet J, Harold MU, et al. The most appropriate treatment would be? Cervical radiculopathy is a clinical condition characterized by unilateral arm pain, numbness and tingling in a dermatomal distribution in the hand, and weakness in specific muscle groups associated with a single cervical nerve root. - Neuromuscular Scoliosis 12/16/2020 13 views 0.0 (0) See More See Less. She denies back pain and states she began her menses 3 months ago. It is sometimes involved with muscle rigidity and sometimes with muscle looseness. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. PSF to pelvis for Neuromuscular Scoliosis, Anterior Cervical Diskectomy and Fusion with Plate and Peak Cage (ACDF), Posterior Cervical Laminectomy and Fusion, Posterior Laminectomy and Instrumented Fusion, Single Level Lumbar Decompression and Fusion (TLIF), MRI for very atypical curves or if there are other concerns, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, check spinal radiographs in 3 months, 6 months and annually postoperatively to look for evidence of any implant complications, repeat xrays of entire spine (PA/lateral sitting), advance spine restrictions and activity levels, diagnosis and management of late complications, has at least 2 units of blood typed and crossed for I and D or hardware removal, need to carefully document neurological status of bilateral lower extremities, strength, sensation, reflexes, and primary symptoms, PA and lateral radiographic films of the entire spine, confirms no recent infection contraindicating surgery (UTI), describe complications of surgery including, implant misplacement, migration or failure, neurologic injury: loss of motor, sensation or bowel/bladder function, Determines upper and lower instrumented vertebra, Understands indications for including pelvis in fusion, describe the steps of the procedure to the attending prior to the start of the case, describe potential complications and steps to avoid them, neuromonitoring leads to upper and lower extremities for SSEPs and MEPs, Blood products available- typically 2 units PRBCs typed and crossed, prone with arms at 90° max shoulder abduction and elbow flexion to prevent axillary nerve injury, pads over ASIS and padding (gel, foam or pillows) on knees, hips and knees flexed (may flex hips more in cases of severe lordosis), Halofemoral traction may be helpful to passively correct curve and pelvic obliquity, When significant weight is being used for traction, blood pressure should be elevated, the more the hips are flexed, the more hyperlordosis of the lumbar spine will be passively corrected, however, be careful not to flex hips so much that the pelvis cannot be imaged because the thighs limit position of C-arm, make a midline incision starting from upper instrumented vertebrae all the way down to the sacrum, make the incision through the dermal layer only, deepen the incision to the level of the spinous processes, use weitlaner retractors to retract the skin margins, identify the interspinous ligament between the spinous process, as the incision is deepened, keep the retractors (weitlaner, cerebellar) tight to help with the exposure and to minimize the amount of bleeding, incise the cartilaginous caps overlying the spinous processes and expose the spinous process staying in the subperiosteal plane, perform dissection with Cobb and bovie electrocautery laterally out to the level of the transverse process, while exposing, move the weitlaner retractors to a deeper position for retraction and hemostasis, it is easier to dissect from caudad to cephalad because of the oblique attachments of the short rotator muscles and ligaments of the spine, generally the primary surgeon works from caudad to cephalad while the assistant works from cephalad to caudad so that they can dissect simultaneously, coagulate the branch of the segmental vessel just lateral to each facet, if placing SAI screws expose laterally to identify S1 and S2 foramen, using the same skin incision, identify and incise the fascia just lateral to the posterior superior iliac spine (PSIS) on each side, subperiosteally dissect the lateral iliac wing down to the sciatic notch, use Taylor or Sofield retractors to facilitate the exposure, expose the bone of the PSIS by using a rongeur to remove the fibrocartilaginous tissue at the PSIS, the T12 rib can also be used to aid in localizing the levels, starting point between the S1 and S2 foramen, in line with S1 pedicle screw starting point, Insert pedicle probe/awl and advance until resistance from sacroiliac joint is in encountered, angle towards greater trochanter, approximately 40° laterally and 40° caudally, though this varies with pelvic obliquity/deformity, Use c-arm fluoroscopy to confirm that tract is just above the level of the sciatic notch, use orthogonal imaging perpendicular to the tract of the probe and parallel to the probe, i.e. She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. What risk factor is most associated with progression of idiopathic scoliosis to a curve requiring surgery? Neuromuscular scoliosis is one of three main types of scoliosis that cause an irregular curvature of the spine. ORTHO BULLETS Orthopaedic Surgeons & Providers 4. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. She had her first menses last month and her Tanner-Whitehouse staging is consistent with an adolescent steady state. Background: Patients with neuromuscular scoliosis (NMS) can pose treatment challenges related to medical comorbidities and altered spinopelvic anatomy. It is caused by nerve root compression in the cervical spine either from degenerative changes or from an acute soft disc hernation. Make a person 's shoulders or waist appear uneven by learning to stand up straight seen Figure. 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