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Spondylolysis and Spondylolisthesis for Postgraduate Orthopaedic Exams
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Spondylolysis and Spondylolisthesis for Postgraduate Orthopaedic Exams
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Segment:0 .
So I'm going to suggest that we move on to. A lumbers, spondylitis, theses and spondylitis, and I'll let you carry on, thank you. OK all right, great. So this will be. This is covering lumbar spondylitis and spinal thesis.
So it's one of the licenses is the effect of the past into a so the parsing into articulates is the segment of the bone that connects the superior article process to the inferior articular process of that vertebra. And it's one of the most commonest causes back pain in the adolescent. And it's most commonly seen in adolescents who are very active, especially in hypertension sports such as gymnasts or other athletes involved in lots of extension activities.
Incidences between 4.4 and 6% and the L5 vertebral body is the most commonly affected. There's different types of spinal lysis, so it's type is the most common and is attributed to a stress fracture of the past from repeated hyperextension. The dysplastic type is less common, and it's caused by congenital deficiency of the inferior facets of Alphaeus. And all the superior facets of S1 and elongation of cars.
Uh, in terms of diagnosing a plane, lack of X-rays are difficult for diagnosis and oblique X-ray creates what's called the Scottish dog review, and the paths in class is seen as a line across the neck of the dog or the collar. So you can see on that radiograph, there's a lytic area across the neck of that dog, and that is the positive effect. Mris can also be used, but they have. They're not as accurate as a CT in terms of diagnosing a defect, and a CT is quite useful in managing a positive effect, as it can see, as increased uptake suggests that this is an active defect which has a potential to heal, were as one with little uptake suggests that it is a cold lesion, which may not heal.
And all of this will help you with planning your management of a patient with the defect. Generally, when you see a patient with back pain and diagnosis of positive effect, you manage them with analgesia. If they're quite active, you would advise a trial of activity restriction, refer them to see a physiotherapist. And quite often I would brace them as well.
So a trial of bracing for about three months, and this actually has quite a high success rate. And if despite conservative measures, they continue to have pain, which causes disability for them again, I would get further imaging CT scan or a CT scan. And if it does, if they still have ongoing pain, I would then also get an MRI scan. Also, because an MRI scan is important for me to look at the disk space.
So if it's an L5 defect, I want to look at the I want to look at the disk space to see if there's any degeneration. If there's no disk degeneration and there's no significant slippage of one virtual body on the other, I would consider a direct paths of repair. Whereas if there's evidence of disk degeneration or a loss thesis of greater than grade one, I would consider a lumbar fusion.
So this is an example of a direct repair, so this patient has a el4 positive effect, and I got an MRI prior to surgery. And it showed that there was no evidence of this degeneration at L4 L5. And also, this patient had no interest theses at L4 five, so this was a candidate for a direct repair. Moving on to respond to this thesis.
So regards respond to this thesis. You've got to know the classification, this is the world sea and human classification, which divides on this thesis into type one, which is dysplastic type 2 systemic type III degenerative. So make is when you've got paths, defect and it causes the subluxation. Dysplastic is when you've got abnormalities, such as an elongated pause, which then leads to the loss theses type 3's degenerative, which you see in the older population where you've got wear and tear of the facet joints and of the capsule that causes the sliding of across the facet, joints and the spinal theses traumatic associated with fractures.
So you can get dramatic fracture paths, fractures or pedicle fractures, which then cause the thesis and pathologic, which could essentially be associated with infection or tumors. The made in classification will classify you in terms of the severity of the slippage, so grade 1 is up to break up the superior end plate of the display at L five s, one of the vertical body below into four conference.
So grade 1 is a slippage of approximately 25% Grade 2's up to 50% grade 3 is up to 75% Grade 4 is when it's just hinging at the edge and grade 5 is bundle of ptosis when it completely comes off the end plate below. So when to consider surgery. So these patients will quite often present with back pain, but also with leg pain symptoms as well. So if you've got a, say, an L5 S1 slip as the L5 vertebral body slips forward, it will compress the L5 foramen L5 nerves coming out of the L5 Freeman as the L5 vertebrae slips over S1, and then they will get bilateral L5 ridiculous.
So the patient with, say, a little exceptionalist thesis the younger population, they are more likely to get the four aminul tenodesis as one vertebral body slips over the other. The degenerative patients, the older patients, they are more likely to have central tenodesis because there's more of a degenerative process over a long time. So they'll have the flavor hypertrophy and the more central tenodesis.
So they'll present more with symptoms of neurogenic complication rather than fractional allopathy. They may present with neurological deficits they could present with food drops as the L5 nerve root gets compressed from an $571 thesis. Or they may get symptoms from an imbalance, so increase back pain, fatigue. And so you consider surgery when you try all non operative measures with analgesia physiotherapy.
And despite all of that, they still have symptoms. You can consider surgery or you consider surgery if they have acute neurological deficits. Another indication for surgery would be slip progression. So another question you may get asked in during your examination is when would you fix these little theses inside you as they are and when would you reduce them? So there's don't necessarily need to know this classification, but this is a more up to date classification of diseases, and it helps you decide which ones to fix and you and which ones to reduce.
So in this classification, essentially, if you've got a spotless thesis, which is low grade generally, which is either grade 1 or grade two, you can fix them inside. It's not necessary to reduce them. When you have high grade spondylitis thesis, you have to determine whether this is a balanced, balanced spine and pelvis or not. And if it's a balanced spine and pelvis, you could do an inside your Fusion if there is compensation.
If the pelvis is compensating for the imbalanced spine with the retro retrofitted pelvis, then you should more consider a partial reduction in Fusion. A complete reduction is a more riskier option simply because the nerve is used to being in a certain position, and if you overproduce it, you could injure that nerve and that could result in permanent neurological injury and foot drops.
So when we're talking, so an important part about deciding whether to reduce or to not reduce is whether it's a low grade or a high grade slip, and if it's a high grade slip, you have to decide whether it is as if the patient is balanced or not balanced. And when we're talking about balanced and balanced, we're asking is the pelvis and is the body compensating for an unbalanced, unbalanced spine?
So when we're talking about balance, sagittal balance on the certain terms that we should know, such as the pelvic incidence, so pelvic incidence is an angle that's measured. So you draw a line from the center of the femoral head to the midpoint of the sacrum. Another line from the midpoint of the sacrum perpendicular to the skull to the sacrum. And that angle between these two lines is that pelvic incidence, which is a fixed angle for each individual.
This has quite a big range, but most often is between 50 and 55 degrees, and this does not change during a patient's lifetime. And another important thing is lump a low doses, which is usually measured from LLL one to S1. And usually if you have a balanced spine, the lumbar low doses and the pelvic incidence should be similar, or 5 to 10 degrees away from each other. So when there's a big mismatch between the pelvic incidence and the lumbar low doses, it comes to your mind that maybe this is there is an imbalance in the sagittal balance of this patient.
Other things to measure all the sacral slope, so you draw a line, a horizontal line from the posterior corner of the spectrum and measured that to the circle and pleat. And you also measure that pelvic tilt, so vertical line straight up from the midpoint of the female femoral head. And another line to the midpoint of the SQL athlete, and that angle is pelvic tilt. So the pelvic incidence is a combination of the pelvic tilt and the cervical slope.
Pelvic tilt values normally between 11 and 15 degrees, and it's a very important indicator of pelvic reversion. So when you're having a pelvic tilt above 50 degrees, you know that the pelvis is compensating by retribution for an abnormal shaped spine. And when you see these compensation measures, that's when you start thinking, perhaps I should think about reducing this spine rather than just fixing it inside you.
So when the spine is imbalanced with, say, for example, spinal diseases, the body compensates by pelvic retribution, by knee flexion, ankle extension, reducing thoracic kyphosis and also flexing the hip as well. So you'll see a patient walking with the imbalanced spine, with knees flexed, hips flexed and just trying to keep themselves upright. The advantage of reducing the spontaneous thesis and fixing it is that you get a better restoration of sagittal balance, you get higher union rates and better for annual decompression.
And the potential disadvantages are increased risk of neurological injury and all of the neurological injuries, most often temporary. Another thing you may get asked about in your vivos or clinical stations is about what happens. What do you do with ptosis? So you should probably just have an idea that there's such a thing as against procedure for ptosis, where essentially you can see in this diagram where L 5 is completely fallen off anteriorly from the sacrum.
And in such a procedure, you enter anteriorly and you completely remove the L5 vertebral body and then you reduce the elph over to a body onto the sacrum and fix it from pastorally. So you go anteriorly as the first stage and the second stage, you go posteriorly and reduced form the sacrum and fix it there. OK, thank you.
OK, thank you again. That was another excellent lecture and, you know, a really good summary of what you need to know and what you need to demonstrate when you're in your exams. Certainly when I was doing my exams, those issues of pelvic incidents and things, I had struggled to get my head around that. So again, I'd suggest you watch that lecture again just to revise your knowledge.
So we've had a couple of questions. We've got one from Kalish who asks, what type of race would you use in spondylitis? One of those as well, I mean, you could either use a usually I use a lumbar brace, some people just use a lumbar corset, or you can actually use a more harder brace like a jacket, like a polycarbonate brace. So, you know, I usually use a kind of a harder brace just to reduce their stop movement as much as possible.
And I think the most important thing is that activity restriction, so you generally find that once they stop doing their sports and a period of rest, it makes a huge difference. Thank you. We've got a question from Jensen. He's asked, is neuromuscular scoliosis further classified into an upper motor neuron lesion and a lower motor neuron lesion as in spastic versus paralytic type?
And so it's broken down into, yes, neuropathic and myopathy. And then you break it down into upper motor neuron and also lower motor neuron, which is either the classic signs of up material with the spasticity or no motor neuron where you've got the more flaccid paralysis. Yes, thank you. But a question from Teaneck. What physiotherapy do you recommend to a patient with spondylitis?
So again, it's basically core muscle strengthening exercises to start to help offload the pressures going through the spine. So build up your spinal muscles, the glue, steels and the upper back as well to help divert forces away from the lower back. Thank you. And the last question we've got from Abdullah. What is the difference between a peel off and a posterior fusion?
Uh, so a cliff and a positive effusion, so when you fusing the spine, you in terms of instrumented fusion, you can just have what's called a post-raw lateral instrumented fusion, which just means putting, say, at L four or five, just putting pedicle screws in both sides. Then you D coordinate the facets and the transverse processes and just put some bone graft to the back.
So there you're just trying to get fusion around the back with a posterior lumbar interbody fusion that means you're putting your screws and everything else, but you also need to take off a bit of the laminar get into the disk space. Take out the disk and then put a Cajun filled with bone graft. And here you're trying to get fusion across the and across the disk space a.
So a push to a lateral instrumented fusion or a post instrumented fusion, you're trying to get fusion only through the back. When you're doing a posterior lumbar interbody fusion, you're trying to get fusion through the front through the disk space using a cage. OK, that's fantastic, thank you very much. So what we'll move on to now is the polling question with the NICU questions, so Ruth will share the polling questions with you.
And if you just answer the questions and we'll see how well you've been listening. Mr althoff, would you like to comment on the questions and the answers, please? Yeah, sure. So the first question was in infantile Scalia's infantile idiopathic scoliosis, which of the following factors suggested progression. So the options were age at presentation, rib overlap of apical vertebra, rib vertebral angle, difference of greater than 15 degrees and male gender.
So, so when you answer these questions, you have to some more than one question could be correct. So which factors suggest progression? So clearly, age progression could suggest it as well. But but you have to. That's not an incorrect answer on its own. The last one male gender male, it's more predominant male gender, but it's not a factor that would predict progression reversible angle difference of greater than 15 degrees.
The threshold is actually 20 degrees, so that's not correct. So the correct answer, which which is the majority you've answered is number two, which is the rib overlap of the apical vertebra, so that if you remember that slide on the phase of the rib, so that would be. The rib phase two. So that would be the rib phase two where you've got the overlap of the apical vertebra on the convex side.
So that's the correct answer. And well done. Most of you got that right. And the second one, the question was in patients with adolescent idiopathic scoliosis, brassic is indicated in which of the following conditions. Um, I can't seem to see the last option on my thing. So scroll down, Farhan on the right hand side, just on Napoleon, you should be able to scroll down.
Yeah I can't seem to do that, so what was the percentage for the last answer and two? 60 60 percent, OK, so so for this day, so for this question. So the first answer was any patient with a curve greater than 25 degrees, so that's not correct. So if a patient has safe, the patient is reserve for is a five. He's finished growth, so they don't require bracing.
What about a girl who's risen 4 with a curve of 30 degrees? OK, 30 degrees is worrying. You may consider bracing, but there is a fall, so the growth is pretty much finished. So there's no point raising this patient 11-year-old boy with a common goal of 50 degrees. Well, he's already beyond the threshold for placing so curves 45 degrees or more. You do not brace because this patient should be considered for surgery and looks like most of you have got the correct answer, which is premenopausal girl with a common cold angle of 30 degrees.
Again, 30 degrees is a worrying number, especially when it's premenopausal, because that means that she's still going to approach a growth spurt. So this patient may actually end up requiring surgery despite the bracing. Question three congenital anomalies or vertebral column are frequently associated with organ system problems in addition to x-rays of the spine. What are the screening tests, should you be ordered?
So the first answer is spine MRI and coagulation profile. That's incorrect because of coagulation profile would not be too helpful. Second answer renal ultrasound, upper and lower GI. That's again, a very vague answer. What does that mean? Upper and lower gi? The third answer renal ultrasound, cardiac evaluation, echocardiogram, spinal MRI.
That is the correct answer because congenital scoliosis associated with renal abnormalities in up to 40% cardiac abnormalities in up to 10% And also MRI abnormalities up to 35% The last answer is incorrect because again, in it, it talks about upper and lower gi, which is not very specific. I can't see the answers for that. What was the 83% to three number? Yeah, the third one.
Yeah all right. Good excellent. Well done, everyone. That's great. I'll stop sharing now back to you and Nicola. Thank you. Thank you, everyone, for answering the MSCI questions. What we're going to do now is we're going to move on to the live.
Segment:0 .
So I'm going to suggest that we move on to. A lumbers, spondylitis, theses and spondylitis, and I'll let you carry on, thank you. OK all right, great. So this will be. This is covering lumbar spondylitis and spinal thesis.
So it's one of the licenses is the effect of the past into a so the parsing into articulates is the segment of the bone that connects the superior article process to the inferior articular process of that vertebra. And it's one of the most commonest causes back pain in the adolescent. And it's most commonly seen in adolescents who are very active, especially in hypertension sports such as gymnasts or other athletes involved in lots of extension activities.
Incidences between 4.4 and 6% and the L5 vertebral body is the most commonly affected. There's different types of spinal lysis, so it's type is the most common and is attributed to a stress fracture of the past from repeated hyperextension. The dysplastic type is less common, and it's caused by congenital deficiency of the inferior facets of Alphaeus. And all the superior facets of S1 and elongation of cars.
Uh, in terms of diagnosing a plane, lack of X-rays are difficult for diagnosis and oblique X-ray creates what's called the Scottish dog review, and the paths in class is seen as a line across the neck of the dog or the collar. So you can see on that radiograph, there's a lytic area across the neck of that dog, and that is the positive effect. Mris can also be used, but they have. They're not as accurate as a CT in terms of diagnosing a defect, and a CT is quite useful in managing a positive effect, as it can see, as increased uptake suggests that this is an active defect which has a potential to heal, were as one with little uptake suggests that it is a cold lesion, which may not heal.
And all of this will help you with planning your management of a patient with the defect. Generally, when you see a patient with back pain and diagnosis of positive effect, you manage them with analgesia. If they're quite active, you would advise a trial of activity restriction, refer them to see a physiotherapist. And quite often I would brace them as well.
So a trial of bracing for about three months, and this actually has quite a high success rate. And if despite conservative measures, they continue to have pain, which causes disability for them again, I would get further imaging CT scan or a CT scan. And if it does, if they still have ongoing pain, I would then also get an MRI scan. Also, because an MRI scan is important for me to look at the disk space.
So if it's an L5 defect, I want to look at the I want to look at the disk space to see if there's any degeneration. If there's no disk degeneration and there's no significant slippage of one virtual body on the other, I would consider a direct paths of repair. Whereas if there's evidence of disk degeneration or a loss thesis of greater than grade one, I would consider a lumbar fusion.
So this is an example of a direct repair, so this patient has a el4 positive effect, and I got an MRI prior to surgery. And it showed that there was no evidence of this degeneration at L4 L5. And also, this patient had no interest theses at L4 five, so this was a candidate for a direct repair. Moving on to respond to this thesis.
So regards respond to this thesis. You've got to know the classification, this is the world sea and human classification, which divides on this thesis into type one, which is dysplastic type 2 systemic type III degenerative. So make is when you've got paths, defect and it causes the subluxation. Dysplastic is when you've got abnormalities, such as an elongated pause, which then leads to the loss theses type 3's degenerative, which you see in the older population where you've got wear and tear of the facet joints and of the capsule that causes the sliding of across the facet, joints and the spinal theses traumatic associated with fractures.
So you can get dramatic fracture paths, fractures or pedicle fractures, which then cause the thesis and pathologic, which could essentially be associated with infection or tumors. The made in classification will classify you in terms of the severity of the slippage, so grade 1 is up to break up the superior end plate of the display at L five s, one of the vertical body below into four conference.
So grade 1 is a slippage of approximately 25% Grade 2's up to 50% grade 3 is up to 75% Grade 4 is when it's just hinging at the edge and grade 5 is bundle of ptosis when it completely comes off the end plate below. So when to consider surgery. So these patients will quite often present with back pain, but also with leg pain symptoms as well. So if you've got a, say, an L5 S1 slip as the L5 vertebral body slips forward, it will compress the L5 foramen L5 nerves coming out of the L5 Freeman as the L5 vertebrae slips over S1, and then they will get bilateral L5 ridiculous.
So the patient with, say, a little exceptionalist thesis the younger population, they are more likely to get the four aminul tenodesis as one vertebral body slips over the other. The degenerative patients, the older patients, they are more likely to have central tenodesis because there's more of a degenerative process over a long time. So they'll have the flavor hypertrophy and the more central tenodesis.
So they'll present more with symptoms of neurogenic complication rather than fractional allopathy. They may present with neurological deficits they could present with food drops as the L5 nerve root gets compressed from an $571 thesis. Or they may get symptoms from an imbalance, so increase back pain, fatigue. And so you consider surgery when you try all non operative measures with analgesia physiotherapy.
And despite all of that, they still have symptoms. You can consider surgery or you consider surgery if they have acute neurological deficits. Another indication for surgery would be slip progression. So another question you may get asked in during your examination is when would you fix these little theses inside you as they are and when would you reduce them? So there's don't necessarily need to know this classification, but this is a more up to date classification of diseases, and it helps you decide which ones to fix and you and which ones to reduce.
So in this classification, essentially, if you've got a spotless thesis, which is low grade generally, which is either grade 1 or grade two, you can fix them inside. It's not necessary to reduce them. When you have high grade spondylitis thesis, you have to determine whether this is a balanced, balanced spine and pelvis or not. And if it's a balanced spine and pelvis, you could do an inside your Fusion if there is compensation.
If the pelvis is compensating for the imbalanced spine with the retro retrofitted pelvis, then you should more consider a partial reduction in Fusion. A complete reduction is a more riskier option simply because the nerve is used to being in a certain position, and if you overproduce it, you could injure that nerve and that could result in permanent neurological injury and foot drops.
So when we're talking, so an important part about deciding whether to reduce or to not reduce is whether it's a low grade or a high grade slip, and if it's a high grade slip, you have to decide whether it is as if the patient is balanced or not balanced. And when we're talking about balanced and balanced, we're asking is the pelvis and is the body compensating for an unbalanced, unbalanced spine?
So when we're talking about balance, sagittal balance on the certain terms that we should know, such as the pelvic incidence, so pelvic incidence is an angle that's measured. So you draw a line from the center of the femoral head to the midpoint of the sacrum. Another line from the midpoint of the sacrum perpendicular to the skull to the sacrum. And that angle between these two lines is that pelvic incidence, which is a fixed angle for each individual.
This has quite a big range, but most often is between 50 and 55 degrees, and this does not change during a patient's lifetime. And another important thing is lump a low doses, which is usually measured from LLL one to S1. And usually if you have a balanced spine, the lumbar low doses and the pelvic incidence should be similar, or 5 to 10 degrees away from each other. So when there's a big mismatch between the pelvic incidence and the lumbar low doses, it comes to your mind that maybe this is there is an imbalance in the sagittal balance of this patient.
Other things to measure all the sacral slope, so you draw a line, a horizontal line from the posterior corner of the spectrum and measured that to the circle and pleat. And you also measure that pelvic tilt, so vertical line straight up from the midpoint of the female femoral head. And another line to the midpoint of the SQL athlete, and that angle is pelvic tilt. So the pelvic incidence is a combination of the pelvic tilt and the cervical slope.
Pelvic tilt values normally between 11 and 15 degrees, and it's a very important indicator of pelvic reversion. So when you're having a pelvic tilt above 50 degrees, you know that the pelvis is compensating by retribution for an abnormal shaped spine. And when you see these compensation measures, that's when you start thinking, perhaps I should think about reducing this spine rather than just fixing it inside you.
So when the spine is imbalanced with, say, for example, spinal diseases, the body compensates by pelvic retribution, by knee flexion, ankle extension, reducing thoracic kyphosis and also flexing the hip as well. So you'll see a patient walking with the imbalanced spine, with knees flexed, hips flexed and just trying to keep themselves upright. The advantage of reducing the spontaneous thesis and fixing it is that you get a better restoration of sagittal balance, you get higher union rates and better for annual decompression.
And the potential disadvantages are increased risk of neurological injury and all of the neurological injuries, most often temporary. Another thing you may get asked about in your vivos or clinical stations is about what happens. What do you do with ptosis? So you should probably just have an idea that there's such a thing as against procedure for ptosis, where essentially you can see in this diagram where L 5 is completely fallen off anteriorly from the sacrum.
And in such a procedure, you enter anteriorly and you completely remove the L5 vertebral body and then you reduce the elph over to a body onto the sacrum and fix it from pastorally. So you go anteriorly as the first stage and the second stage, you go posteriorly and reduced form the sacrum and fix it there. OK, thank you.
OK, thank you again. That was another excellent lecture and, you know, a really good summary of what you need to know and what you need to demonstrate when you're in your exams. Certainly when I was doing my exams, those issues of pelvic incidents and things, I had struggled to get my head around that. So again, I'd suggest you watch that lecture again just to revise your knowledge.
So we've had a couple of questions. We've got one from Kalish who asks, what type of race would you use in spondylitis? One of those as well, I mean, you could either use a usually I use a lumbar brace, some people just use a lumbar corset, or you can actually use a more harder brace like a jacket, like a polycarbonate brace. So, you know, I usually use a kind of a harder brace just to reduce their stop movement as much as possible.
And I think the most important thing is that activity restriction, so you generally find that once they stop doing their sports and a period of rest, it makes a huge difference. Thank you. We've got a question from Jensen. He's asked, is neuromuscular scoliosis further classified into an upper motor neuron lesion and a lower motor neuron lesion as in spastic versus paralytic type?
And so it's broken down into, yes, neuropathic and myopathy. And then you break it down into upper motor neuron and also lower motor neuron, which is either the classic signs of up material with the spasticity or no motor neuron where you've got the more flaccid paralysis. Yes, thank you. But a question from Teaneck. What physiotherapy do you recommend to a patient with spondylitis?
So again, it's basically core muscle strengthening exercises to start to help offload the pressures going through the spine. So build up your spinal muscles, the glue, steels and the upper back as well to help divert forces away from the lower back. Thank you. And the last question we've got from Abdullah. What is the difference between a peel off and a posterior fusion?
Uh, so a cliff and a positive effusion, so when you fusing the spine, you in terms of instrumented fusion, you can just have what's called a post-raw lateral instrumented fusion, which just means putting, say, at L four or five, just putting pedicle screws in both sides. Then you D coordinate the facets and the transverse processes and just put some bone graft to the back.
So there you're just trying to get fusion around the back with a posterior lumbar interbody fusion that means you're putting your screws and everything else, but you also need to take off a bit of the laminar get into the disk space. Take out the disk and then put a Cajun filled with bone graft. And here you're trying to get fusion across the and across the disk space a.
So a push to a lateral instrumented fusion or a post instrumented fusion, you're trying to get fusion only through the back. When you're doing a posterior lumbar interbody fusion, you're trying to get fusion through the front through the disk space using a cage. OK, that's fantastic, thank you very much. So what we'll move on to now is the polling question with the NICU questions, so Ruth will share the polling questions with you.
And if you just answer the questions and we'll see how well you've been listening. Mr althoff, would you like to comment on the questions and the answers, please? Yeah, sure. So the first question was in infantile Scalia's infantile idiopathic scoliosis, which of the following factors suggested progression. So the options were age at presentation, rib overlap of apical vertebra, rib vertebral angle, difference of greater than 15 degrees and male gender.
So, so when you answer these questions, you have to some more than one question could be correct. So which factors suggest progression? So clearly, age progression could suggest it as well. But but you have to. That's not an incorrect answer on its own. The last one male gender male, it's more predominant male gender, but it's not a factor that would predict progression reversible angle difference of greater than 15 degrees.
The threshold is actually 20 degrees, so that's not correct. So the correct answer, which which is the majority you've answered is number two, which is the rib overlap of the apical vertebra, so that if you remember that slide on the phase of the rib, so that would be. The rib phase two. So that would be the rib phase two where you've got the overlap of the apical vertebra on the convex side.
So that's the correct answer. And well done. Most of you got that right. And the second one, the question was in patients with adolescent idiopathic scoliosis, brassic is indicated in which of the following conditions. Um, I can't seem to see the last option on my thing. So scroll down, Farhan on the right hand side, just on Napoleon, you should be able to scroll down.
Yeah I can't seem to do that, so what was the percentage for the last answer and two? 60 60 percent, OK, so so for this day, so for this question. So the first answer was any patient with a curve greater than 25 degrees, so that's not correct. So if a patient has safe, the patient is reserve for is a five. He's finished growth, so they don't require bracing.
What about a girl who's risen 4 with a curve of 30 degrees? OK, 30 degrees is worrying. You may consider bracing, but there is a fall, so the growth is pretty much finished. So there's no point raising this patient 11-year-old boy with a common goal of 50 degrees. Well, he's already beyond the threshold for placing so curves 45 degrees or more. You do not brace because this patient should be considered for surgery and looks like most of you have got the correct answer, which is premenopausal girl with a common cold angle of 30 degrees.
Again, 30 degrees is a worrying number, especially when it's premenopausal, because that means that she's still going to approach a growth spurt. So this patient may actually end up requiring surgery despite the bracing. Question three congenital anomalies or vertebral column are frequently associated with organ system problems in addition to x-rays of the spine. What are the screening tests, should you be ordered?
So the first answer is spine MRI and coagulation profile. That's incorrect because of coagulation profile would not be too helpful. Second answer renal ultrasound, upper and lower GI. That's again, a very vague answer. What does that mean? Upper and lower gi? The third answer renal ultrasound, cardiac evaluation, echocardiogram, spinal MRI.
That is the correct answer because congenital scoliosis associated with renal abnormalities in up to 40% cardiac abnormalities in up to 10% And also MRI abnormalities up to 35% The last answer is incorrect because again, in it, it talks about upper and lower gi, which is not very specific. I can't see the answers for that. What was the 83% to three number? Yeah, the third one.
Yeah all right. Good excellent. Well done, everyone. That's great. I'll stop sharing now back to you and Nicola. Thank you. Thank you, everyone, for answering the MSCI questions. What we're going to do now is we're going to move on to the live.
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