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Paediatric Spine Deformities for Postgraduate Orthopaedic Exams
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Paediatric Spine Deformities for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Over three mq questions, which we'd like you to answer. And then we will move on to the vyver session. Now the vyver session will be for questions of 12 minutes each, plus 3 minutes of feedback. We've only got capacity for candidates today, so if you'd like to take part in the vyver, if you raise your hand and put a message in the chat box, letting us know when you're taking the clinical exams and we will try to accommodate you, we will give priority to those sitting in November and in the order in which they let us know.
And I'd just want to remind you all that we. Do you produce a book called concise orthopedic notes, which is very useful in preparation, and we would like some feedback at the end of the session. And Ruth will send you the feedback forms for that, so I'm going to introduce Mr. Farhan Althoff. He qualified from symbolic slap of both St Barts and the Royal London Hospital in 2002.
He had received the Jackson burrows and Morton prize for Outstanding academic achievement as a medical student, and he trained in the Northwest Thames London rotation and achieved his completion of surgical training in 2015. He was a consultant at the Royal National orthopedic hospital and prior to this, he undertook further subspecialist training, including one year spinal fellowship at the Vancouver General Hospital in Canada and a one year spinal fellowship at the Royal North Shore Hospital in Sydney, Australia.
He also worked as a fellow for three months in Lyon in France. Ottawa is currently a consultant spine surgeon in Australia, and we would like to welcome him. And thank him for these presentations. And so I'll hand over to you, Mr alter. I have everybody. Thank you very much for inviting me to give these lectures and presentations and Viva sessions.
So we'll get started on the first lecture. The first lecture is on pediatric spinal deformity. And so the contents of this lecture will cover adolescent idiopathic scoliosis, infantile scoliosis, congenital scoliosis and syndromic scoliosis. The definition of scoliosis is essentially it's a three dimensional deformity of the spine, defined as a lack of curvature of the spine in the coronal plane of more than 10 degrees.
When you defining and categorizing scoliosis, there's three essentially three major types you can divide it into congenital syndromic and idiopathic. Regards to idiopathic scoliosis. It can be further subdivided based on age, so infantile, scoliosis is between 0 to 3 years, juvenile is between 3 and 10 and adolescent is greater than 10.
Another way of classifying it is either early onset or late onset. So early onset is below 10 years old and late onset is beyond 10 years. Regards to adolescent idiopathic scoliosis, the etiology the Egypt pathology is very diverse, is considered to be a multifactorial disease with genetic predisposing factors.
The prevalence is 2 to three and overall there's a female preponderance in regards to his natural history. This was studied in a prospective case series of about 133 patients, which they followed up for an average of 40 years. And they found that thoracic curves greater than 50 degrees tend to be progressive approximately one degree per year as compared to thorax lawmakers, which progressed at 0.5 degrees and lumbar curves, which progressed a point to four.
They found that thoracic occurs below 30 degrees did not progress. When you approach and take a history from a patient with adolescent idiopathic scoliosis, you have to ask them what they're presenting. Complaint is, patients are often present with unlevel shoulders. Waistline is sanitary. They may complain that one hip is sticking out or a prominence.
This is most usually identified by the patient themselves or a family member or the general practitioner. Sometimes the patients will present with back pain. Um, during your history, it's important to ask about what they're presenting complaint is, including back pain and whether they have any neurological symptoms, any pain on paresthesia and upper and lower limbs, and also concerns regarding because Mrs. You also want to get a good pain history as well if they're complaining of pain.
Do they have constant pain? Do they have NIPE pain? Ridiculous pain? This is to look for any underlying pathology, such as to exclude tumors and other red flags. It's also very important to get a good birth history, so any difficulties during labor may be associated with cerebral palsy and potentially other non-indian forms of scoliosis.
You also want to ask about developmental milestones. When were they able to sit up? When will they walk it? They have they achieved their developmental milestones throughout development? Again, if they have developmental delay, this can suggest a non idiopathic form of scoliosis. Also, you want to ask questions to assess the physiological maturity, so you may want to ask inquire about the growth spurt.
And if it's a female, you want to ask about the maniacal status because the onset of menarche suggests that growth starts to slow down from that point for about two years from the onset of menarche. With regards to the examination, clearly you want starting off with inspection to do an adequate inspection, you want adequate exposure.
So for so for boys, you want to be in their underwear or shorts, and if it was a girl, it would be a bra and their underwear. So first of all, you want to inspect them. You want to look at their shoulder heights to see if there's any asymmetry of their shoulders. You want to look at their pelvis and again, asymmetry of the pelvis. You then also want to evaluate their gait as well.
So you want to look at the gait and their posture when you get them to walk. You especially looking for any short leg gait and to evaluate for leg length and discrepancy. You want to see if the listing to one side or the other. And then during the inspection process, you're looking for specific signs that is this a non idiopathic type of scoliosis? So you're looking for a cafe Au lait spots, which can indicate neurofibromatosis.
You're looking for axillary fettling again indicating neurofibromatosis on your forehead. You also look at the back to look for any hairy patches or skin dimpling, which could suggest a spinal disk racism, such as spina bifida in the patient's upright posture. You want to again evaluate them from the front, the back and the sides. You want to evaluate the height of the iliac crest, their shoulders.
You want to also then see if they do actually. Can you actually see a spinal curvature? If you see a spinal curvature, is it in the thoracic spine? Is the lumbar spine, and you basically described it according to the complexity of the curve. So if you see a thoracic curve, which is convex to the right hand side, then it becomes a right sided curve. And as you can see in this photo, this patient is having their coronal alignment assessed.
So essentially, the dropping a line or a tape or a thread on the C7 spine is process, and they're looking at how far it's deviated from the beautiful cleft cleft or the midline of the sacrum. And then you're looking for. Ideally, it should just go through the midline. If it's deviated more to the right side. Then there's coronal imbalance to the right.
And if it's to the left side, there's a kernel imbalance to the left. You also want to evaluate for leg length discrepancy. So essentially, if you feel that on examination when they're standing up, there's asymmetry in their height of the iliac crests, you may put some wooden blocks to get the pelvic level if there's a leg length discrepancy. And at that point, you see whether the scoliosis is still present or not, because essentially leg Glenn discrepancy can cause a postural scoliosis.
So you're seeing is it a postural scoliosis or is it a structural scoliosis? Another way to eliminate leg length discrepancies, get the patient to sit down on a chair, and that eliminates the leg length discrepancy. And then you're seeing, is the scoliosis still there or not? Um, subsequently, it's very important to perform the atoms Forward Bend test here with the patient standing up and the knees extended.
You get the patient to bend forward with the hands together. And here you're looking for the rib prominence, which you can see on the spot on this photograph on the right hand side. And again, you're looking whether the scoliosis is still present or not, because if it's a postural scoliosis on the Adam Forward Bend test, it will disappear. It has a structure one will remain.
And then subsequently, last of all, an examination is important to a thorough neurological examination and during the neurological examination, it's also very important to do the abdominal reflexes. So when doing the abdominal reflexes, essentially you're dividing the abdomen into four quadrants around the umbilicus and you use the end of a patellar tendon hammer and you stroke each of the four quadrants.
And what you would expect is the umbilicus to move towards the point of stimulation with your patellar tendon hammer. And this should be symmetrical, all in all, for confidence when there is a symmetry, this is suggestive of spinal disk racism or an underlying disorder, and this would be an indication to get an MRI scan. Regards to imaging, you want to get full length play and lateral view X-rays of the whole spine and lateral bending views would be used for surgical planning to evaluate for the flexibility of the curve, which will help you guide fixation levels.
Regards to curve patterns, the majority of the curves are right thoracic. And again, there's a lengthy classification which you do not need to know for the exams, but essentially will define the different patterns of curves that are seen. But essentially, you can get thoracic curves, lumbar curves, combination of those curves and sometimes and when you quite often when you have a structural curve, which is a main curve, then you get a compensatory curve to try to balance it out as well.
When you see a left thoracic curve, that's of concern because that is unusual and it's usually associated with underlying spinal distress. So when I'm talking about spinal racism, I'm talking about conditions within the spine, such as dysnomia to my ears, the most common form of spinal racism on occurring malformation syringe Amelia, which means the presence of a syrinx on or Chiari malformations which can be associated with herniation of the brain contents through the foramen magnum and also into the spinal lipoma or cord tethering.
And so when you see a left sided thoracic curve, you'd consider an MRI scan. When you get your X-rays up to measure the size of the curve, you need to know what the invertebrates are. You need to decide on the invertebrates. So the invertebrates are the vertebral bodies in the proximal and distal aspect of the curves, which are most tilted towards the concavity of the curve.
So what you then do is decide on your superior and vertebra, inferior and vertebra. You draw a line along the superior and plate of the superior and vertebra. You draw a line along the inferior end plate of the inferior and vertebra and then you draw perpendicular lines. Those two lines and then the cross section of that, that angle is formed by the cabango, and the core bangle is important to measure in every single patient with scoliosis, because this will help you plan treatment and to determine whether the curve is progressing.
And it's usually important to have the same and vertebra in your mind and documentation to subsequently measure progression. Risk factors for progression, so age is important, so the younger you are, the greater potential you have for growth and curve progression. Females are more likely to progress, menarche is important to know because progression is least after menarche, it slows down for two years afterwards.
And other measurements, which I'll describe in the subsequent slide is a sign which can help you determine progression, which is a measurement of the progression of the iliac apotheosis curve patterns can also indicate progression. Double curves progress more frequently, the single curves and also clearly curve magnitude. So assessing curve progression, there's different ways of assessing curve progression.
Again, there is, you know, there's different staging methods, so there's a Tanner staging method, which looks at secondary sexual characteristics. It's not as reliable as the more skeletal methods. So other methods are the using hand X rays, such as the Sanders staging system, which is staged from 1 to eight. And there's also one by Dimaggio, which looks as a hypothesis around the elbow.
The one that's more commonly used is the ERISA staging method, which evaluates the progression of the offices from the anterior superior iliac spine to the posterior iliac spine and terminates with Fusion with the iem, as well as six grades from 0 to 6 with 0 and 1 at the early stages where there's lots of growth and growth, tapers off at 4 and completes at 5 when the iliac offices completely fuses with the spine.
So when do you consider breast treatment? So brace treatment is generally considered for curves greater than 25 degrees and in the immature spine. So when we talk about results 0 and 1 and above 25 degrees, that would be a candidate for bracing. You you could consider bracing patients with curves less than 25 degrees if they show evidence of progression.
So progression means the curve increases by greater than 5 degrees at two consecutive follow up appointments, which are either four or six months apart from each other. And you can also consider it for higher curves, 30, 40 degrees if they still have growth left. This, but there's no point in doing. I mean, there's little benefit from bracing patients 30, 40 degrees who are reserve for reserve, five who are pretty much finished growth.
So the contraindications were great, things are curves over 45 degrees, because these should be these patients should be considered more for surgery. And also children who have completed growth because bracing again, will not be effective. So when do you consider surgery, so surgery again is concert. Overall, about 10% of patients with adolescent idiopathic scoliosis were progressed to surgery, so surgery is generally indicated to treat a significant clinical deformity.
So significant clinical deformity would be a curvature 45 to 50 degrees, and also to correct the skull deformity that is likely to progress. So say an immature patients just about to enter the adolescent growth spurt has a 30 degree curve already. And if and you know that if you leave this patient, brace them, it's still not going to be enough to control the curve.
So such a patient with a smaller curve will still require surgery as you know that there's going to, you know, it's going to progress quite rapidly during the growth spurt. So evidence of curved progression would be again, another indication for surgery in terms of surgical treatment options. There's different ways of approaching it. The most common surgical approach would be a posterior fusion of the spine, and essentially the aim of the surgical procedure would be to fuse this as fuse as little motion segments as possible.
A fuse across the curve. Try to get a balanced spine and to have high fusion rates as well. So generally, it's done procedurally. But if you've got a very solitary curve such as solitary lumbar curve or thoracic, you can make it. You can use a purely anterior approach, which can be seen on the radiograph on the left hand side, or if you've got a very stiff curve where on the bending views, where you've still got a curve about 60 degrees, you may need to do an anterior release where you go through the anteriorly and you take out all the disk spaces and insert bone grafting cages and then go through the back and fix it.
That's what very stiff curves. Moving on to another category, which is infantile, scoliosis, so infantile, scoliosis is pretty much the opposite. Here you see it more commonly in boys, whereas in adolescent idiopathic, scoliosis is mainly in girls. And this is categorized between birth and three years.
There's an increased association with hip dysplasia, mental retardation, congenital heart disease, and many of these curves will actually resolve spontaneously. But those that progress have to be taken seriously because this is the important period where your lung is going to be developed. Lung development goes up to about the age of eight. So any severe curve at this level can have a significantly detrimental effect on your lung function and.
The costovertebral angle is very important to know this is first described by minetta from who was working at the Royal National orthopedic hospital. Daniel, originally from calcutta, and she basically said her interest was looking at the early detection of progression. Progressive curves in the aim of her study was to define a radiological method for differentiating between resolving and progressive curves.
At this early age in infantile scoliosis, and also to examine the influence of the early growth spurt on progressive curves. So she described the sort of virtual angle difference to help distinguish between progressive and resolving curbs in infantile scoliosis. So to measure the vertical angle difference, you need to define the atypical vertebra, which is the vertebra in the center of the curve.
Then you draw a line, a perpendicular line down the center of your vertebral body, which is known as the vertebral line. And then on either side, you draw a line down through the rib, head and neck to the point intersects with that vertical line and measure that angle on both sides. And the difference between these. The angle on the cavity and the convexity of the curve is called the vertical angle difference.
If this value is below 20 degrees, the study found that the curves did not progress, whereas if the angle was greater than 20 degrees, they would progress and hence such patients would need treatment. She also described the phase of the rip head, so in the face of the rib head. You again looking on the convexity of the curve to see if that rib had overlaps with the vertebral body.
She found that if it didn't overlap with the vertebral body described as phase one, such curves did not progress. Whereas whereas if a curve was in phase two, she found phase two where there's overlap of the convex rib head with the vertical body. These curves definitely did progress. So a progressive curve, a shift from phase 1 to phase two suggests that it's a progressive curve.
So in phase one, if a curve is if the rib head is in phase one, it could either progress or not progress. So in these patients, you measure the VAD to measure to see if it's above or below 20 degrees, if it's entered phase two. That means it's definitely going to progress, and there's not even any point of measuring our body at that point because it is, by definition, a progressive curve.
In terms of management of such patients, it's ideally you want to try avoiding fusing these patients because they still have lung growth available, they have spine growth available. You've also got to remember that you don't want to ideally fuse the spine until the age of 10, because that's when by the age of 10, 80% of your vertebral height has been achieved. So you know, you're more you're more comfortable fusing the spine at that point.
And clearly, you want to achieve a long growth until the age of eight. So this is a lot of these children are treated with casting on a special table, which is either known as a RZA table or a metal table, and these costs have changed every 6 to 12 weeks. And generally, these infantile scoliosis cases, you'll start casting these curves when they reach about 60 degrees.
And the aim is then to reduce the size of the curves to about 50. And then at that point, you might start bracing them. Um, and if they then still continue to progress despite costing and bracing. You you may look at non fusion surgical methods. So these are the growing rod techniques which allow the spine. Allow control of the curve whilst allowing the spine to grow in the lungs to develop.
So it's different types of growth friendly systems, such as growing rods. So you can have single rods, dual rods or on this photograph, you can see magnetic growth rods which use, which has a magnet where you can control outside the patient to achieve sequential destruction. There's other techniques, such as staples, tethers and other techniques, such as Luke and Schiller techniques, but they all have the same concept of controlling the curve whilst allowing the spine to grow and the lungs to develop.
Moving on to congenital scoliosis, so congenital scoliosis is lateral curvature of the spine secondary to a vertebral anomaly that causes an imbalance in longitudinal growth of the spine. So embryology, the 5 to six week of is when the spine develops, and this is when the defect occurs and the etiology is multifactorial with the approximate prevalence of 1 in 1,000 births.
And this typically occurs in the thoracic spine. 60% are associated congenital abnormal abnormalities, and you should know the bacterial mnemonic V stands for Virtual anomalies, ace stands for anorectal anomalies, C stands for cardiac t for tracheal abnormalities, E for esophageal or for renal and L for limb. So neural access abnormalities are seen quite often on an MRI scan, so these patients should have MRI scans.
Also, watch out for the lower limb abnormalities, which can be diverse from asymmetric calves to kivus feet to club feet to vertical tail. Also, a proportion of them will have congenital problems in genitourinary problems also. In terms of classification of these deformities, so you can divide them into failure or formation, which can be incomplete. So in example of incomplete failure, formation is a wedge vertebra, which has this wedge shaped.
But the but the wedge vertebra will still have both its particles intact. And you can also have a complete failure of formation, which means the formation of a hemi vertebra as opposed to a wedge vertebra. So in an hemi vertebra, there will be an absence of one pedicle in one part and a segment of the vertebral body. Also, hemi vertebrae are classified as either fully segmented, where the hammer vertebra has a intact disk above and below.
Partially segmented means the hemi vertebra is either fused to the vertical body above and below, so it only has one disk space and segmented means that it's fused to the vertebral body and above and below. So there's no disk spaces adjacent to the hemi vertebra. So this diagram again on the left hand side, is a fully segmented hemi vertebra. The middle one is partially segmented and the one on the right is augmented.
And the second classification of congenital and congenital abnormalities would be failure of segmentation, so this can either be a unilateral failure of segmentation, which results in the formation of a bar which acts as unilateral growth together. Or you can have a bilateral, which results in a block vertebra. In terms of progression, 25% of these hemi vertebra showed no progression, 50% progress rapidly and 25 progressed.
25% progress slowly, progression more likely up to five years of age and during puberty and the one the combination to watch out for is the mixed type, where you've got a unilateral bar on one side with a contralateral fully segmented hemi vertebra on the other side, which has a worse prognosis and most likely to progress. In terms of surgical treatment, generally, you would again prognosticate depends on the configuration.
So if it's progressive, you would more likely to consider surgery or if it's greater than 40 degrees, you're more likely to consider surgery. The aim of the surgical options to obtain a balanced spine. Whilst maintaining flexibility. There's different ways of approaching it. Initially, you may consider non-surgical treatment methods, such as bracing.
In spite of that, if it's progressive, you may consider a growing rod techniques. If it still continues to progress with deformities, you can consider inside your Fusion or if there's a significant deformity already with an imbalanced spine, you could consider a hemi vertebral excision, which could involve you can do completely posterior, or it can involve anterior and posterior approach.
The moving onto syndromic scoliosis, and this includes a large number of conditions that could cause it. So you divide it into neuromuscular neuromuscular scoliosis can be divided into neuropathic in my empathic. And each of these have a number of conditions under the categories, and I'll go over some of them because they're quite relevant to the exams.
You might get them as clinical patients or in vivo stations or even a mix. And so Brugada syndrome is scoliosis, they generally tend to have long c-shaped curves with rapid progression is more common, can lead to thoracic insufficiency syndrome. Pelvic obliquity is more common associated with hip fractures and dislocation. The aims of treatment is to maintain cardiorespiratory function, promote mobility and ablation and preserve sitting balance.
An example would be cerebral palsy is a condition in this category. The most common cause of neuromuscular scoliosis. Then these curves can continue past maturity, bracing, effective only in the ambulatory patients. Scoliosis is more common in the GMFCS grade 4 and five, so it's important to note mfcc's, which is graded from 1 to 5. So one is when they're mobile and 5 is when they're pretty much completely dependent in a wheelchair.
So once they become more immobile, they're more likely to have the scoliosis when you're fixing these curves. You need to fix them down to the pelvis to address the pelvic obliquity other conditions. Duchenne muscular dystrophy this is an X linked recessive progressive myopathic involving skeletal and cardiac muscle and involves a gene that encodes dystrophin, which is a protein that stabilizes muscle cell membranes and presence, usually in the preschool male.
The child usually presents with falls clumsiness to walking. Other clinical signs would be suda hypertrophy of the calves. One blood test that you would ask for is CPK, which would be elevated significantly. Another common sign is a Gower's sign where the child essentially uses his hands to push off, with the legs extended to try to stand up because of the muscle weakness and steroids have significantly improved the prognosis.
Spinal muscular atrophy is a genetic condition. This, for different types of SMA type 1 is lethal as an infant type to where the infant can't walk. Type 3 is the child is normal up until about 18 months and they regress and type 4 occurs as an adult. It's a progressive loss of alpha motor neurons in the anterior horn of the spinal cord, and essentially proximal weakness moves through distally throughout the body, and surgery should be considered early in these patients.
Friedrichs ataxia to spinocerebellar degenerative disease autosomal recessive and this onset usually occurs a bit later on, usually in the 20s, as opposed to the other form of scoliosis. And these patients can present with ataxia a reflex here and also other associated anomalies such as keeping various feet and death is usually from cardiomyopathy in these patients.
Rett syndrome is a neurodevelopmental disorder with x-linked dominant inheritance. And these patients also have normal development up to about six to 18 months, and they start regressing with mental retardation, spasticity and significant behavioral anomalies as well. And with 50% unable to walk by 10 years. It's also important to know about mile and meninga, the spectrum of disorders, so spina bifida or culture where this failure of formation of the bony elements of the spine, which failed to fuse.
But these patients have no neurological deficits. Meningococcal is when there is the dura and the tissue overlying the spinal cord pouch out through the bone defect. But the spinal cord remains intact, so there's little neurological impairment. While the meningococcal is a more severe form where actually the neural elements pouch out and may even be completely exposed. And this can be associated with significant neurological deficits.
Under other condition is another condition associated with scoliosis is neurofibromatosis, which is autism dominant and again, on examination, you might find cafe a cafe. All these thoughts and to diagnose neurofibromatosis, you need six caffé Allen spots greater than 5 and you also need to neurofibromatosis.
One plexiform neurofibromas reflect threatening radiographs may show vertebral scalloping penciling of ribs in large parameter. There's two types of curves. There's the usual curve nondestructive curve of neurofibrillary fiber mitosis, which is just like the curves you see with adolescent idiopathic scoliosis and you manage it just like that. And you also get the dystrophin curves, which are more worrying, which are typically thoracic associated with kyphosis and have a sharp angulation.
And these tend to progress more rapidly and more frequently require surgical treatment. And when you treat these curves, they also have a higher association with pseudoviruses. Quite often, you may need to go through the front and to the back to fuse these curves. Thank you. So that's the first lecture, so I'll now move on to the second lecture.
Hi, Mr. Atif. We've just got a couple of questions. I just wanted to say thank you. That was a beautiful lecture and it's very comprehensive and I'd encourage all the candidates to review that lecture. I think it's set out very clearly what sometimes a difficult subject, especially in exams, because often trainees are not exposed to pediatric spine deformities.
So and it does come up in all components of the exam. So I'd encourage you to take on board Mr. altarpiece examination tips and summaries. So we've just got a couple of questions. We've got a question from Jenny, which is, what is the success rate of bracing in controlling a curve progression? OK again, there was a study from called the breast study, which looked at bracing for adolescent idiopathic scoliosis.
And they found that it reduced your incidence of requiring surgery by about a third. But again, that requires compliance with best treatment because the best outcomes is if you're getting wearing a brace up to 23 hours a day, definitely greater than 16 hours a day. But it's very, I would say it's very successful at controlling curves. Idiopathic curves, especially if you catch them early on.
OK, thank you. I hope that answers your question, Jenny. So we've got one from nagasu. She's or he's put what treatment options do you recommend for a resource limited area? And so treatment options for. I mean, I think, you know, clearly non operative treatment methods such as bracing, bracing or casting, you know, if bracing is not available, then casting as an option also.
And but, you know, if you're going into instrumentation, clearly all of that going to be pretty expensive. So as I say, I'm a strong supporter of bracing and I think it would be very effective in resource strapped areas. Yeah, that's great. Thank you. We've got enjin yang who wants to know, is there a difference between syndromic scoliosis and neuromuscular scoliosis?
Well, I think neuromuscular scoliosis comes under the category of syndromic scoliosis. So syndromic scoliosis, I would say, would encompass neuromuscular scoliosis and also other disorders such as neurofibromatosis. And there's also other conditions linked to scoliosis, such as conditions associated with ligaments, laxity such as more fans and ehlers-danlos syndrome.
And they would all come under syndromic as well. So neuromuscular is a subcategory of syndromic berlioz's. I think that's very clear. Thank you. And the last question I've got from ESA and he's asked, how do you choose your surgical approach, anterior or posterior? And what would your indications be for each?
Yeah so if you've got AI mean, so most scoliosis can be done posteriorly. There are certain curves where you've got to just take a single lumbar curve, the lumbar curve or a single thoracic curve. You could do it, And the advantage of doing anteriorly is that you can make a shorter fixation. So the aim of any scoliosis is try to keep as many mobile segments as possible.
The advantage of anterior scoliosis that you can fuse shorter. So if you've got a small, if you've just got a thoracolumbar curve, you could just go anteriorly and fuse that curve. Other indications for going anteriorly is to release. So if you've got a very stiff curve, so on a bending view, it's still very stiff. Going pastorally may not be enough to straighten that or loosen up that curve, so then you have to really take all the disk space, do the releases to loosen it up.
And then go. Really? Yeah. OK
Segment:0 .
Over three mq questions, which we'd like you to answer. And then we will move on to the vyver session. Now the vyver session will be for questions of 12 minutes each, plus 3 minutes of feedback. We've only got capacity for candidates today, so if you'd like to take part in the vyver, if you raise your hand and put a message in the chat box, letting us know when you're taking the clinical exams and we will try to accommodate you, we will give priority to those sitting in November and in the order in which they let us know.
And I'd just want to remind you all that we. Do you produce a book called concise orthopedic notes, which is very useful in preparation, and we would like some feedback at the end of the session. And Ruth will send you the feedback forms for that, so I'm going to introduce Mr. Farhan Althoff. He qualified from symbolic slap of both St Barts and the Royal London Hospital in 2002.
He had received the Jackson burrows and Morton prize for Outstanding academic achievement as a medical student, and he trained in the Northwest Thames London rotation and achieved his completion of surgical training in 2015. He was a consultant at the Royal National orthopedic hospital and prior to this, he undertook further subspecialist training, including one year spinal fellowship at the Vancouver General Hospital in Canada and a one year spinal fellowship at the Royal North Shore Hospital in Sydney, Australia.
He also worked as a fellow for three months in Lyon in France. Ottawa is currently a consultant spine surgeon in Australia, and we would like to welcome him. And thank him for these presentations. And so I'll hand over to you, Mr alter. I have everybody. Thank you very much for inviting me to give these lectures and presentations and Viva sessions.
So we'll get started on the first lecture. The first lecture is on pediatric spinal deformity. And so the contents of this lecture will cover adolescent idiopathic scoliosis, infantile scoliosis, congenital scoliosis and syndromic scoliosis. The definition of scoliosis is essentially it's a three dimensional deformity of the spine, defined as a lack of curvature of the spine in the coronal plane of more than 10 degrees.
When you defining and categorizing scoliosis, there's three essentially three major types you can divide it into congenital syndromic and idiopathic. Regards to idiopathic scoliosis. It can be further subdivided based on age, so infantile, scoliosis is between 0 to 3 years, juvenile is between 3 and 10 and adolescent is greater than 10.
Another way of classifying it is either early onset or late onset. So early onset is below 10 years old and late onset is beyond 10 years. Regards to adolescent idiopathic scoliosis, the etiology the Egypt pathology is very diverse, is considered to be a multifactorial disease with genetic predisposing factors.
The prevalence is 2 to three and overall there's a female preponderance in regards to his natural history. This was studied in a prospective case series of about 133 patients, which they followed up for an average of 40 years. And they found that thoracic curves greater than 50 degrees tend to be progressive approximately one degree per year as compared to thorax lawmakers, which progressed at 0.5 degrees and lumbar curves, which progressed a point to four.
They found that thoracic occurs below 30 degrees did not progress. When you approach and take a history from a patient with adolescent idiopathic scoliosis, you have to ask them what they're presenting. Complaint is, patients are often present with unlevel shoulders. Waistline is sanitary. They may complain that one hip is sticking out or a prominence.
This is most usually identified by the patient themselves or a family member or the general practitioner. Sometimes the patients will present with back pain. Um, during your history, it's important to ask about what they're presenting complaint is, including back pain and whether they have any neurological symptoms, any pain on paresthesia and upper and lower limbs, and also concerns regarding because Mrs. You also want to get a good pain history as well if they're complaining of pain.
Do they have constant pain? Do they have NIPE pain? Ridiculous pain? This is to look for any underlying pathology, such as to exclude tumors and other red flags. It's also very important to get a good birth history, so any difficulties during labor may be associated with cerebral palsy and potentially other non-indian forms of scoliosis.
You also want to ask about developmental milestones. When were they able to sit up? When will they walk it? They have they achieved their developmental milestones throughout development? Again, if they have developmental delay, this can suggest a non idiopathic form of scoliosis. Also, you want to ask questions to assess the physiological maturity, so you may want to ask inquire about the growth spurt.
And if it's a female, you want to ask about the maniacal status because the onset of menarche suggests that growth starts to slow down from that point for about two years from the onset of menarche. With regards to the examination, clearly you want starting off with inspection to do an adequate inspection, you want adequate exposure.
So for so for boys, you want to be in their underwear or shorts, and if it was a girl, it would be a bra and their underwear. So first of all, you want to inspect them. You want to look at their shoulder heights to see if there's any asymmetry of their shoulders. You want to look at their pelvis and again, asymmetry of the pelvis. You then also want to evaluate their gait as well.
So you want to look at the gait and their posture when you get them to walk. You especially looking for any short leg gait and to evaluate for leg length and discrepancy. You want to see if the listing to one side or the other. And then during the inspection process, you're looking for specific signs that is this a non idiopathic type of scoliosis? So you're looking for a cafe Au lait spots, which can indicate neurofibromatosis.
You're looking for axillary fettling again indicating neurofibromatosis on your forehead. You also look at the back to look for any hairy patches or skin dimpling, which could suggest a spinal disk racism, such as spina bifida in the patient's upright posture. You want to again evaluate them from the front, the back and the sides. You want to evaluate the height of the iliac crest, their shoulders.
You want to also then see if they do actually. Can you actually see a spinal curvature? If you see a spinal curvature, is it in the thoracic spine? Is the lumbar spine, and you basically described it according to the complexity of the curve. So if you see a thoracic curve, which is convex to the right hand side, then it becomes a right sided curve. And as you can see in this photo, this patient is having their coronal alignment assessed.
So essentially, the dropping a line or a tape or a thread on the C7 spine is process, and they're looking at how far it's deviated from the beautiful cleft cleft or the midline of the sacrum. And then you're looking for. Ideally, it should just go through the midline. If it's deviated more to the right side. Then there's coronal imbalance to the right.
And if it's to the left side, there's a kernel imbalance to the left. You also want to evaluate for leg length discrepancy. So essentially, if you feel that on examination when they're standing up, there's asymmetry in their height of the iliac crests, you may put some wooden blocks to get the pelvic level if there's a leg length discrepancy. And at that point, you see whether the scoliosis is still present or not, because essentially leg Glenn discrepancy can cause a postural scoliosis.
So you're seeing is it a postural scoliosis or is it a structural scoliosis? Another way to eliminate leg length discrepancies, get the patient to sit down on a chair, and that eliminates the leg length discrepancy. And then you're seeing, is the scoliosis still there or not? Um, subsequently, it's very important to perform the atoms Forward Bend test here with the patient standing up and the knees extended.
You get the patient to bend forward with the hands together. And here you're looking for the rib prominence, which you can see on the spot on this photograph on the right hand side. And again, you're looking whether the scoliosis is still present or not, because if it's a postural scoliosis on the Adam Forward Bend test, it will disappear. It has a structure one will remain.
And then subsequently, last of all, an examination is important to a thorough neurological examination and during the neurological examination, it's also very important to do the abdominal reflexes. So when doing the abdominal reflexes, essentially you're dividing the abdomen into four quadrants around the umbilicus and you use the end of a patellar tendon hammer and you stroke each of the four quadrants.
And what you would expect is the umbilicus to move towards the point of stimulation with your patellar tendon hammer. And this should be symmetrical, all in all, for confidence when there is a symmetry, this is suggestive of spinal disk racism or an underlying disorder, and this would be an indication to get an MRI scan. Regards to imaging, you want to get full length play and lateral view X-rays of the whole spine and lateral bending views would be used for surgical planning to evaluate for the flexibility of the curve, which will help you guide fixation levels.
Regards to curve patterns, the majority of the curves are right thoracic. And again, there's a lengthy classification which you do not need to know for the exams, but essentially will define the different patterns of curves that are seen. But essentially, you can get thoracic curves, lumbar curves, combination of those curves and sometimes and when you quite often when you have a structural curve, which is a main curve, then you get a compensatory curve to try to balance it out as well.
When you see a left thoracic curve, that's of concern because that is unusual and it's usually associated with underlying spinal distress. So when I'm talking about spinal racism, I'm talking about conditions within the spine, such as dysnomia to my ears, the most common form of spinal racism on occurring malformation syringe Amelia, which means the presence of a syrinx on or Chiari malformations which can be associated with herniation of the brain contents through the foramen magnum and also into the spinal lipoma or cord tethering.
And so when you see a left sided thoracic curve, you'd consider an MRI scan. When you get your X-rays up to measure the size of the curve, you need to know what the invertebrates are. You need to decide on the invertebrates. So the invertebrates are the vertebral bodies in the proximal and distal aspect of the curves, which are most tilted towards the concavity of the curve.
So what you then do is decide on your superior and vertebra, inferior and vertebra. You draw a line along the superior and plate of the superior and vertebra. You draw a line along the inferior end plate of the inferior and vertebra and then you draw perpendicular lines. Those two lines and then the cross section of that, that angle is formed by the cabango, and the core bangle is important to measure in every single patient with scoliosis, because this will help you plan treatment and to determine whether the curve is progressing.
And it's usually important to have the same and vertebra in your mind and documentation to subsequently measure progression. Risk factors for progression, so age is important, so the younger you are, the greater potential you have for growth and curve progression. Females are more likely to progress, menarche is important to know because progression is least after menarche, it slows down for two years afterwards.
And other measurements, which I'll describe in the subsequent slide is a sign which can help you determine progression, which is a measurement of the progression of the iliac apotheosis curve patterns can also indicate progression. Double curves progress more frequently, the single curves and also clearly curve magnitude. So assessing curve progression, there's different ways of assessing curve progression.
Again, there is, you know, there's different staging methods, so there's a Tanner staging method, which looks at secondary sexual characteristics. It's not as reliable as the more skeletal methods. So other methods are the using hand X rays, such as the Sanders staging system, which is staged from 1 to eight. And there's also one by Dimaggio, which looks as a hypothesis around the elbow.
The one that's more commonly used is the ERISA staging method, which evaluates the progression of the offices from the anterior superior iliac spine to the posterior iliac spine and terminates with Fusion with the iem, as well as six grades from 0 to 6 with 0 and 1 at the early stages where there's lots of growth and growth, tapers off at 4 and completes at 5 when the iliac offices completely fuses with the spine.
So when do you consider breast treatment? So brace treatment is generally considered for curves greater than 25 degrees and in the immature spine. So when we talk about results 0 and 1 and above 25 degrees, that would be a candidate for bracing. You you could consider bracing patients with curves less than 25 degrees if they show evidence of progression.
So progression means the curve increases by greater than 5 degrees at two consecutive follow up appointments, which are either four or six months apart from each other. And you can also consider it for higher curves, 30, 40 degrees if they still have growth left. This, but there's no point in doing. I mean, there's little benefit from bracing patients 30, 40 degrees who are reserve for reserve, five who are pretty much finished growth.
So the contraindications were great, things are curves over 45 degrees, because these should be these patients should be considered more for surgery. And also children who have completed growth because bracing again, will not be effective. So when do you consider surgery, so surgery again is concert. Overall, about 10% of patients with adolescent idiopathic scoliosis were progressed to surgery, so surgery is generally indicated to treat a significant clinical deformity.
So significant clinical deformity would be a curvature 45 to 50 degrees, and also to correct the skull deformity that is likely to progress. So say an immature patients just about to enter the adolescent growth spurt has a 30 degree curve already. And if and you know that if you leave this patient, brace them, it's still not going to be enough to control the curve.
So such a patient with a smaller curve will still require surgery as you know that there's going to, you know, it's going to progress quite rapidly during the growth spurt. So evidence of curved progression would be again, another indication for surgery in terms of surgical treatment options. There's different ways of approaching it. The most common surgical approach would be a posterior fusion of the spine, and essentially the aim of the surgical procedure would be to fuse this as fuse as little motion segments as possible.
A fuse across the curve. Try to get a balanced spine and to have high fusion rates as well. So generally, it's done procedurally. But if you've got a very solitary curve such as solitary lumbar curve or thoracic, you can make it. You can use a purely anterior approach, which can be seen on the radiograph on the left hand side, or if you've got a very stiff curve where on the bending views, where you've still got a curve about 60 degrees, you may need to do an anterior release where you go through the anteriorly and you take out all the disk spaces and insert bone grafting cages and then go through the back and fix it.
That's what very stiff curves. Moving on to another category, which is infantile, scoliosis, so infantile, scoliosis is pretty much the opposite. Here you see it more commonly in boys, whereas in adolescent idiopathic, scoliosis is mainly in girls. And this is categorized between birth and three years.
There's an increased association with hip dysplasia, mental retardation, congenital heart disease, and many of these curves will actually resolve spontaneously. But those that progress have to be taken seriously because this is the important period where your lung is going to be developed. Lung development goes up to about the age of eight. So any severe curve at this level can have a significantly detrimental effect on your lung function and.
The costovertebral angle is very important to know this is first described by minetta from who was working at the Royal National orthopedic hospital. Daniel, originally from calcutta, and she basically said her interest was looking at the early detection of progression. Progressive curves in the aim of her study was to define a radiological method for differentiating between resolving and progressive curves.
At this early age in infantile scoliosis, and also to examine the influence of the early growth spurt on progressive curves. So she described the sort of virtual angle difference to help distinguish between progressive and resolving curbs in infantile scoliosis. So to measure the vertical angle difference, you need to define the atypical vertebra, which is the vertebra in the center of the curve.
Then you draw a line, a perpendicular line down the center of your vertebral body, which is known as the vertebral line. And then on either side, you draw a line down through the rib, head and neck to the point intersects with that vertical line and measure that angle on both sides. And the difference between these. The angle on the cavity and the convexity of the curve is called the vertical angle difference.
If this value is below 20 degrees, the study found that the curves did not progress, whereas if the angle was greater than 20 degrees, they would progress and hence such patients would need treatment. She also described the phase of the rip head, so in the face of the rib head. You again looking on the convexity of the curve to see if that rib had overlaps with the vertebral body.
She found that if it didn't overlap with the vertebral body described as phase one, such curves did not progress. Whereas whereas if a curve was in phase two, she found phase two where there's overlap of the convex rib head with the vertical body. These curves definitely did progress. So a progressive curve, a shift from phase 1 to phase two suggests that it's a progressive curve.
So in phase one, if a curve is if the rib head is in phase one, it could either progress or not progress. So in these patients, you measure the VAD to measure to see if it's above or below 20 degrees, if it's entered phase two. That means it's definitely going to progress, and there's not even any point of measuring our body at that point because it is, by definition, a progressive curve.
In terms of management of such patients, it's ideally you want to try avoiding fusing these patients because they still have lung growth available, they have spine growth available. You've also got to remember that you don't want to ideally fuse the spine until the age of 10, because that's when by the age of 10, 80% of your vertebral height has been achieved. So you know, you're more you're more comfortable fusing the spine at that point.
And clearly, you want to achieve a long growth until the age of eight. So this is a lot of these children are treated with casting on a special table, which is either known as a RZA table or a metal table, and these costs have changed every 6 to 12 weeks. And generally, these infantile scoliosis cases, you'll start casting these curves when they reach about 60 degrees.
And the aim is then to reduce the size of the curves to about 50. And then at that point, you might start bracing them. Um, and if they then still continue to progress despite costing and bracing. You you may look at non fusion surgical methods. So these are the growing rod techniques which allow the spine. Allow control of the curve whilst allowing the spine to grow in the lungs to develop.
So it's different types of growth friendly systems, such as growing rods. So you can have single rods, dual rods or on this photograph, you can see magnetic growth rods which use, which has a magnet where you can control outside the patient to achieve sequential destruction. There's other techniques, such as staples, tethers and other techniques, such as Luke and Schiller techniques, but they all have the same concept of controlling the curve whilst allowing the spine to grow and the lungs to develop.
Moving on to congenital scoliosis, so congenital scoliosis is lateral curvature of the spine secondary to a vertebral anomaly that causes an imbalance in longitudinal growth of the spine. So embryology, the 5 to six week of is when the spine develops, and this is when the defect occurs and the etiology is multifactorial with the approximate prevalence of 1 in 1,000 births.
And this typically occurs in the thoracic spine. 60% are associated congenital abnormal abnormalities, and you should know the bacterial mnemonic V stands for Virtual anomalies, ace stands for anorectal anomalies, C stands for cardiac t for tracheal abnormalities, E for esophageal or for renal and L for limb. So neural access abnormalities are seen quite often on an MRI scan, so these patients should have MRI scans.
Also, watch out for the lower limb abnormalities, which can be diverse from asymmetric calves to kivus feet to club feet to vertical tail. Also, a proportion of them will have congenital problems in genitourinary problems also. In terms of classification of these deformities, so you can divide them into failure or formation, which can be incomplete. So in example of incomplete failure, formation is a wedge vertebra, which has this wedge shaped.
But the but the wedge vertebra will still have both its particles intact. And you can also have a complete failure of formation, which means the formation of a hemi vertebra as opposed to a wedge vertebra. So in an hemi vertebra, there will be an absence of one pedicle in one part and a segment of the vertebral body. Also, hemi vertebrae are classified as either fully segmented, where the hammer vertebra has a intact disk above and below.
Partially segmented means the hemi vertebra is either fused to the vertical body above and below, so it only has one disk space and segmented means that it's fused to the vertebral body and above and below. So there's no disk spaces adjacent to the hemi vertebra. So this diagram again on the left hand side, is a fully segmented hemi vertebra. The middle one is partially segmented and the one on the right is augmented.
And the second classification of congenital and congenital abnormalities would be failure of segmentation, so this can either be a unilateral failure of segmentation, which results in the formation of a bar which acts as unilateral growth together. Or you can have a bilateral, which results in a block vertebra. In terms of progression, 25% of these hemi vertebra showed no progression, 50% progress rapidly and 25 progressed.
25% progress slowly, progression more likely up to five years of age and during puberty and the one the combination to watch out for is the mixed type, where you've got a unilateral bar on one side with a contralateral fully segmented hemi vertebra on the other side, which has a worse prognosis and most likely to progress. In terms of surgical treatment, generally, you would again prognosticate depends on the configuration.
So if it's progressive, you would more likely to consider surgery or if it's greater than 40 degrees, you're more likely to consider surgery. The aim of the surgical options to obtain a balanced spine. Whilst maintaining flexibility. There's different ways of approaching it. Initially, you may consider non-surgical treatment methods, such as bracing.
In spite of that, if it's progressive, you may consider a growing rod techniques. If it still continues to progress with deformities, you can consider inside your Fusion or if there's a significant deformity already with an imbalanced spine, you could consider a hemi vertebral excision, which could involve you can do completely posterior, or it can involve anterior and posterior approach.
The moving onto syndromic scoliosis, and this includes a large number of conditions that could cause it. So you divide it into neuromuscular neuromuscular scoliosis can be divided into neuropathic in my empathic. And each of these have a number of conditions under the categories, and I'll go over some of them because they're quite relevant to the exams.
You might get them as clinical patients or in vivo stations or even a mix. And so Brugada syndrome is scoliosis, they generally tend to have long c-shaped curves with rapid progression is more common, can lead to thoracic insufficiency syndrome. Pelvic obliquity is more common associated with hip fractures and dislocation. The aims of treatment is to maintain cardiorespiratory function, promote mobility and ablation and preserve sitting balance.
An example would be cerebral palsy is a condition in this category. The most common cause of neuromuscular scoliosis. Then these curves can continue past maturity, bracing, effective only in the ambulatory patients. Scoliosis is more common in the GMFCS grade 4 and five, so it's important to note mfcc's, which is graded from 1 to 5. So one is when they're mobile and 5 is when they're pretty much completely dependent in a wheelchair.
So once they become more immobile, they're more likely to have the scoliosis when you're fixing these curves. You need to fix them down to the pelvis to address the pelvic obliquity other conditions. Duchenne muscular dystrophy this is an X linked recessive progressive myopathic involving skeletal and cardiac muscle and involves a gene that encodes dystrophin, which is a protein that stabilizes muscle cell membranes and presence, usually in the preschool male.
The child usually presents with falls clumsiness to walking. Other clinical signs would be suda hypertrophy of the calves. One blood test that you would ask for is CPK, which would be elevated significantly. Another common sign is a Gower's sign where the child essentially uses his hands to push off, with the legs extended to try to stand up because of the muscle weakness and steroids have significantly improved the prognosis.
Spinal muscular atrophy is a genetic condition. This, for different types of SMA type 1 is lethal as an infant type to where the infant can't walk. Type 3 is the child is normal up until about 18 months and they regress and type 4 occurs as an adult. It's a progressive loss of alpha motor neurons in the anterior horn of the spinal cord, and essentially proximal weakness moves through distally throughout the body, and surgery should be considered early in these patients.
Friedrichs ataxia to spinocerebellar degenerative disease autosomal recessive and this onset usually occurs a bit later on, usually in the 20s, as opposed to the other form of scoliosis. And these patients can present with ataxia a reflex here and also other associated anomalies such as keeping various feet and death is usually from cardiomyopathy in these patients.
Rett syndrome is a neurodevelopmental disorder with x-linked dominant inheritance. And these patients also have normal development up to about six to 18 months, and they start regressing with mental retardation, spasticity and significant behavioral anomalies as well. And with 50% unable to walk by 10 years. It's also important to know about mile and meninga, the spectrum of disorders, so spina bifida or culture where this failure of formation of the bony elements of the spine, which failed to fuse.
But these patients have no neurological deficits. Meningococcal is when there is the dura and the tissue overlying the spinal cord pouch out through the bone defect. But the spinal cord remains intact, so there's little neurological impairment. While the meningococcal is a more severe form where actually the neural elements pouch out and may even be completely exposed. And this can be associated with significant neurological deficits.
Under other condition is another condition associated with scoliosis is neurofibromatosis, which is autism dominant and again, on examination, you might find cafe a cafe. All these thoughts and to diagnose neurofibromatosis, you need six caffé Allen spots greater than 5 and you also need to neurofibromatosis.
One plexiform neurofibromas reflect threatening radiographs may show vertebral scalloping penciling of ribs in large parameter. There's two types of curves. There's the usual curve nondestructive curve of neurofibrillary fiber mitosis, which is just like the curves you see with adolescent idiopathic scoliosis and you manage it just like that. And you also get the dystrophin curves, which are more worrying, which are typically thoracic associated with kyphosis and have a sharp angulation.
And these tend to progress more rapidly and more frequently require surgical treatment. And when you treat these curves, they also have a higher association with pseudoviruses. Quite often, you may need to go through the front and to the back to fuse these curves. Thank you. So that's the first lecture, so I'll now move on to the second lecture.
Hi, Mr. Atif. We've just got a couple of questions. I just wanted to say thank you. That was a beautiful lecture and it's very comprehensive and I'd encourage all the candidates to review that lecture. I think it's set out very clearly what sometimes a difficult subject, especially in exams, because often trainees are not exposed to pediatric spine deformities.
So and it does come up in all components of the exam. So I'd encourage you to take on board Mr. altarpiece examination tips and summaries. So we've just got a couple of questions. We've got a question from Jenny, which is, what is the success rate of bracing in controlling a curve progression? OK again, there was a study from called the breast study, which looked at bracing for adolescent idiopathic scoliosis.
And they found that it reduced your incidence of requiring surgery by about a third. But again, that requires compliance with best treatment because the best outcomes is if you're getting wearing a brace up to 23 hours a day, definitely greater than 16 hours a day. But it's very, I would say it's very successful at controlling curves. Idiopathic curves, especially if you catch them early on.
OK, thank you. I hope that answers your question, Jenny. So we've got one from nagasu. She's or he's put what treatment options do you recommend for a resource limited area? And so treatment options for. I mean, I think, you know, clearly non operative treatment methods such as bracing, bracing or casting, you know, if bracing is not available, then casting as an option also.
And but, you know, if you're going into instrumentation, clearly all of that going to be pretty expensive. So as I say, I'm a strong supporter of bracing and I think it would be very effective in resource strapped areas. Yeah, that's great. Thank you. We've got enjin yang who wants to know, is there a difference between syndromic scoliosis and neuromuscular scoliosis?
Well, I think neuromuscular scoliosis comes under the category of syndromic scoliosis. So syndromic scoliosis, I would say, would encompass neuromuscular scoliosis and also other disorders such as neurofibromatosis. And there's also other conditions linked to scoliosis, such as conditions associated with ligaments, laxity such as more fans and ehlers-danlos syndrome.
And they would all come under syndromic as well. So neuromuscular is a subcategory of syndromic berlioz's. I think that's very clear. Thank you. And the last question I've got from ESA and he's asked, how do you choose your surgical approach, anterior or posterior? And what would your indications be for each?
Yeah so if you've got AI mean, so most scoliosis can be done posteriorly. There are certain curves where you've got to just take a single lumbar curve, the lumbar curve or a single thoracic curve. You could do it, And the advantage of doing anteriorly is that you can make a shorter fixation. So the aim of any scoliosis is try to keep as many mobile segments as possible.
The advantage of anterior scoliosis that you can fuse shorter. So if you've got a small, if you've just got a thoracolumbar curve, you could just go anteriorly and fuse that curve. Other indications for going anteriorly is to release. So if you've got a very stiff curve, so on a bending view, it's still very stiff. Going pastorally may not be enough to straighten that or loosen up that curve, so then you have to really take all the disk space, do the releases to loosen it up.
And then go. Really? Yeah. OK
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