This techniques allows for which of the following: Submit case scenarios of … Neuromuscular scoliosis is the name given to the type of scoliosis that happens in people with problems with their nervous systems (brain, spinal cord or nerves) or muscles. Neuromuscular Scoliosis Cerebral Palsy - Spinal Disorders ... Spine⎜Disk Space Infection - Pediatric Team Orthobullets 4 Spine - Disk Space Infection - Pediatric; Listen Now 11:38 min. These curves can make a person's shoulders or waist appear uneven. Jevsevar, D.S. A 16-year-old female with adolescent idiopathic scoliosis undergoes posterior spinal fusion with instrumentation. She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. The thoracic pedicle screws were placed using a tap 1 mm smaller than the screw diameter and a straightforward trajectory that runs parallel to the superior endplate. The lumbar curve from T12 to L5 measures 36 degrees, and the thoracic curve from T3 … (OBQ13.61) Compared with idiopathic scoliosis, neuromuscular scoliosis is much more likely to produce curves that progress, and continue progressing into adulthood. Tested Concept, (OBQ11.49) A 13-year-old girl is referred to the orthopedic clinic for evaluation of scoliosis. MB BULLETS Step 1 For 1st and 2nd Year Med Students. teardrop view, remove pedicle probe/awl and probe tract with ball tip to confirm osseous channel and measure tract, for adults a minimum diameter of 8.5mm is typical and this may be appropriate for older teenagers, for younger children a smaller diameter may be necessary, place screw and confirm position with AP and teardrop fluoroscopic images, if orientation of pelvis/imaging is unclear, one can dissect along outer table, then, place finger in depression of sciatic notch to confirm direction of tract, make a separate fascial incision over the PSIS. Neuromuscular scoliosis (NMS) is a type of scoliosis that can occur in children who have medical conditions that impair their ability to control the muscles that support the spine. 384 plays. It is caused by nerve root compression in the cervical spine either from degenerative changes or from an acute soft disc hernation. Radiographs of her spine show an apex left lumbar curve measuring 32 degrees and an apex right thoracic curve measuring 28 degrees. Discontinuation of bracing as she has reached skeletal maturity. Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Occipitocervical Instability & Dislocation, Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Spondylolysis & Spondylolisthesis, predicts the risk of curve progression despite bracing to >50 degrees in Lenke type I and III curves, uses anteroposterior hand radiograph and curve magnitude to assess risk of progression despite bracing, compression of 3rd part of duodenum due to narrowing of the space between SMA and aorta. Which of the following methods of determining skeletal maturity correlates most closely with the curve acceleration phase for children with idiopathic scoliosis? Vertebral column resection involves removing segments of the spine including the body of the vertebra and the posterior elements, which include the lamina, transverse… The presence, severity … 10/21/2019. Spine (Phila Pa 1976), 2010 3. 2015 Apr-May. 20 ABOS Breakdown ABOS 2020 Spine ... • Neuromuscular disease 1.0% 1.5 Neuromuscular Scoliosis 6.0% 9.0 • Thromboembolus 2.0% 3.0 Thromboembolism Observation, to allow time to follow the natural history of the scoliosis, and to reassess decision-making, is a valid treatment option. All of the following should be performed as part of her evaluation EXCEPT: Examination reveals a mild right rib prominence during forward bending. 10/21/2019. In patients with adolescent idiopathic scoliosis, bracing is indicated in which of the following conditions: Tested Concept, (SBQ09SP.17) A PA standing radiograph is shown in Figure A. X-rays of the neck should be taken to look for abnormal vertebrae in this region. consultation with a pain management specialist. An isolated long-segment instrumented posterior spinal fusion is considered in which of the following clinical situations? J Pediatr Orthop. A 12-year-old girl who is 3 months postmenarchal undergoes full-time brace treatment for scoliosis. Figures A-E are radiographs showing varying stages of skeletal maturity. These curves can't be corrected simply by learning to stand up straight. Currently, degenerative scoliosis and traumatic scoliosis are Neuromuscular Scoliosis Cerebral Palsy - Spinal Disorders Pathologic Scoliosis ... Orthobullets Team Spine - Adolescent Idiopathic Scoliosis; Listen Now 16:17 min. 3: p. 14. Defined as idiopathic scoliosis in children, incidence of 3% for curves between 10 to 20°, 1:1 male to female ratio for small curves, cartilaginous plate that forms between the centrum and posterior neural arches, increased incidence of acute and chronic pain in adults if left untreated, curves > 90° are associated with cardiopulmonary dysfunction, early death, pain, and decreased self image, risk factors for progression (at presentation), > 25° before skeletal maturity will continue to progress, > 50° thoracic curve will progress 1-2° / year, > 40° lumbar curve will progress 1-2° / year, Risser 0 covers the first 2/3rd of the pubertal growth spurt, correlates with the greatest velocity of skeletal linear growth, is the best predictor of curve progression, if curve is >30° before peak height velocity there is a strong likelihood of the need for surgery, thoracic more likely to progress than lumber, double curves more likely to progress than single curves, five part classification to describe thoracic curve patterns and help guide surgeons implanting Harrington instrumentation, link to King-Moe classification (not testable), more comprehensive classification based on PA, lateral, and supine bending films, helps to decide upon which curves need to be included within the fusion construct, link to Lenke classification (not testable), patients often referred from school screening where a, axial plane deformity indicates structural curve, can eliminate leg length inequality as cause of scoliosis, other important findings on physical exam, rib rotational deformity (rib prominence), can suggest neural axis abnormalities and warrant a MRI, coronal balance is determined by alignment of, sagittal balance is based on C7 plumb from center of C7 to the posterior-superior corner of S1, between lines drawn vertically from lumbosacral facet joints, most proximal vertebrae that is most closely bisected by central sacral vertical line, rotationally neutral (spinous process equal distance to pedicles on PA xray), end vertebra is defined as the vertebra that is most tilted from the horizontal apical vertebra, the apical vertebraeis the disk or vertebra deviated farthest from the center of the vertebral column, best predictor of postoperative shoulder balance, should extend from posterior fossa to conus, purpose is to rule out intraspinal anomalies, left thoracic curve, short angular curve, apical kyphosis, a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation, Based on skeletal maturity of patient, magnitude of deformity, and curve progression, obtain serial radiographs to monitor for progression, only effective for flexible deformity in skeletally immature patient (Risser 0, 1, 2), goal is to stop progression, not to correct deformity, 50% reduction in need for surgery with compliant brace wear of at least 13 hours a day, poor prognosis with brace treatment associated with, noncompliant (effectiveness is dose related), can be used for all types of idiopathic scoliosis, remains gold standard for thoracic and double major curves (most cases), best for thoracolumbar and lumbar cases with a normal sagittal profile, (Risser grade 0, girls <10 yrs, boys < 13 yrs), recommended for 16-23 hours/day until skeletal maturity or surgical intervention deemed necessary (actual wear minimum 12 hours required to slow progression), Milwaukee brace (cervicothoracolumbosacral orthosis), Charleston Bending brace is a curved night brace, 6° or more curve progression at orthotic discontinuation (skeletal maturity), absolute progression to >45° either before or at skeletal maturity, or discontinuation in favor of surgery, <1cm change in height over 2 visits 6 months apart, fusion should include enough levels to adequately maintain sagittal and coronal balance while being as minimal as safely possible to preserve motion, typical fusion from proximal end vertebra to one or two levels cephalad to the stable vertebra, double and triple major curves fuse to the distal end vertebra, recommends one level above and two levels below the end vertebrae if these levels fall wilthin the stable zone, recommends fusion to the neutral vertebrae, recommends including all major curves in the fusion and minor curves that are not flexible or are kyphotic. She occasionally takes acetaminophen, but the pain does not limit sport activities. It is the second most common form of scoliosis and is associated with disorders of the nerve or muscular systems such as cerebral palsy, spina bifida and spinal cord injury. Awwad W, Al-Ahaideb A, Jiang L, Algarni AD, Ouellet J, Harold MU, et al. After the history and physical examination, the next step in evaluating congenital scoliosis is obtaining x-rays. 20. MB BULLETS Step 1 For 1st and 2nd Year Med Students. It is sometimes involved with muscle rigidity and sometimes with muscle looseness. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Pelvic fixation with Sacral Alar Iliac (SAI) Screws 2. Common conditions that can result in a neuromuscular scoliosis include: Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Tested Concept, Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, Pathogenesis of AIS: Braces & Monitoring: You Can Do It! 1. PSF to pelvis for Neuromuscular Scoliosis, Anterior Cervical Diskectomy and Fusion with Plate and Peak Cage (ACDF), Posterior Cervical Laminectomy and Fusion, Posterior Laminectomy and Instrumented Fusion, Single Level Lumbar Decompression and Fusion (TLIF), MRI for very atypical curves or if there are other concerns, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, check spinal radiographs in 3 months, 6 months and annually postoperatively to look for evidence of any implant complications, repeat xrays of entire spine (PA/lateral sitting), advance spine restrictions and activity levels, diagnosis and management of late complications, has at least 2 units of blood typed and crossed for I and D or hardware removal, need to carefully document neurological status of bilateral lower extremities, strength, sensation, reflexes, and primary symptoms, PA and lateral radiographic films of the entire spine, confirms no recent infection contraindicating surgery (UTI), describe complications of surgery including, implant misplacement, migration or failure, neurologic injury: loss of motor, sensation or bowel/bladder function, Determines upper and lower instrumented vertebra, Understands indications for including pelvis in fusion, describe the steps of the procedure to the attending prior to the start of the case, describe potential complications and steps to avoid them, neuromonitoring leads to upper and lower extremities for SSEPs and MEPs, Blood products available- typically 2 units PRBCs typed and crossed, prone with arms at 90° max shoulder abduction and elbow flexion to prevent axillary nerve injury, pads over ASIS and padding (gel, foam or pillows) on knees, hips and knees flexed (may flex hips more in cases of severe lordosis), Halofemoral traction may be helpful to passively correct curve and pelvic obliquity, When significant weight is being used for traction, blood pressure should be elevated, the more the hips are flexed, the more hyperlordosis of the lumbar spine will be passively corrected, however, be careful not to flex hips so much that the pelvis cannot be imaged because the thighs limit position of C-arm, make a midline incision starting from upper instrumented vertebrae all the way down to the sacrum, make the incision through the dermal layer only, deepen the incision to the level of the spinous processes, use weitlaner retractors to retract the skin margins, identify the interspinous ligament between the spinous process, as the incision is deepened, keep the retractors (weitlaner, cerebellar) tight to help with the exposure and to minimize the amount of bleeding, incise the cartilaginous caps overlying the spinous processes and expose the spinous process staying in the subperiosteal plane, perform dissection with Cobb and bovie electrocautery laterally out to the level of the transverse process, while exposing, move the weitlaner retractors to a deeper position for retraction and hemostasis, it is easier to dissect from caudad to cephalad because of the oblique attachments of the short rotator muscles and ligaments of the spine, generally the primary surgeon works from caudad to cephalad while the assistant works from cephalad to caudad so that they can dissect simultaneously, coagulate the branch of the segmental vessel just lateral to each facet, if placing SAI screws expose laterally to identify S1 and S2 foramen, using the same skin incision, identify and incise the fascia just lateral to the posterior superior iliac spine (PSIS) on each side, subperiosteally dissect the lateral iliac wing down to the sciatic notch, use Taylor or Sofield retractors to facilitate the exposure, expose the bone of the PSIS by using a rongeur to remove the fibrocartilaginous tissue at the PSIS, the T12 rib can also be used to aid in localizing the levels, starting point between the S1 and S2 foramen, in line with S1 pedicle screw starting point, Insert pedicle probe/awl and advance until resistance from sacroiliac joint is in encountered, angle towards greater trochanter, approximately 40° laterally and 40° caudally, though this varies with pelvic obliquity/deformity, Use c-arm fluoroscopy to confirm that tract is just above the level of the sciatic notch, use orthogonal imaging perpendicular to the tract of the probe and parallel to the probe, i.e. With Adam's forward bending, she is noted to have a significant right thoracic rib prominence. Severe scoliosis can be disabling. The exact mechanisms of the condition are not well understood. A detailed neurological examination reveals no abnormalities. Neuromuscular scoliosis is one of three main types of scoliosis that cause an irregular curvature of the spine. Neuromuscular Scoliosis Scoliosis is a condition that causes the spine to curve sideways. The patient represented by which Figure would be expected to have the highest risk of progression of an idiopathic scoliotic curve? She denies pain. difficulty with vaginal child birth in the future. Mullender, M., et al., A Dutch guideline for the treatment of scoliosis in neuromuscular disorders. The Cobb angle is the most widely used measurement to quantify the magnitude of spinal deformities, especially in the case of scoliosis, on plain radiographs.Scoliosis is defined as a lateral spinal curvature with a Cobb angle of >10° 4.A Cobb angle can also aid kyphosis or … Continue full-time bracing until skeletal maturity. therefore, whenever possible, avoid fusion to L4 and L5, it is almost never required to fuse to the pelvis in idiopathic scoliosis, screw insertional torque correlates with resistance to screw pullout, better correction while saving lumbar fusion levels, increased risk of pseudarthrosis when thoracic hyperkyphosis is present, typically fuse from end vertebra to end vertebra, monitoring with somatosensory-evoked potentials (SSEPs) and/or motor-evoked potentials (MEPs) is now the standard of care, motor-evoked potentials can provide an intraoperative warning of impending spinal cord dysfunction, neurologic event defined as drop in amplitude of > 50%, if neurologic injury occurs intraoperatively consider, check hemoglobin and transfuse as necessary, remove instrumentation if the spine is stable, increased risk with kyphosis, excessive correction, and sublaminar wires, presents as late pain, deformity progression, and hardware failure, an asymptomatic pseudarthrosis with no pain and no loss of correction should be observed, attempt I&D with maintenance of hardware if not loose and within 6 months, early fatigability and back pain due to loss of lumbar lordosis, rare now that segmental instrumentation addresses sagittal plane deformities, decreased incidence with rod contouring in the sagittal plane and compression/distraction techniques, treat with revision surgery utilizing posterior closing wedge osteotomies, anterior releases prior to osteotomies aid in maintenance of correction, rotational deformity of the spine created by continued anterior spinal growth in the setting of a posterior spinal fusion, can occur in very young patients when PSF is performed alone and the anterior column is allowed continued growth, avoided by performing anterior diskectomy and fusion with posterior fusion in very young patients, SMA arises from anterior aspect of aorta at level of L1 vertebrae, presents with symptoms of bowel obstruction in first postoperative week, associated with electrolyte abnormalities, height percentile <50%; weight percentile < 25%, late rod breakage can signify a pseudarthrosis. (Curve progression and trunk imbalances are more severe in patients who are not able to walk). Hurler syndrome, also known as mucopolysaccharidosis Type IH (MPS-IH), Hurler's disease, and formerly gargoylism, is a genetic disorder that results in the buildup of large sugar molecules called glycosaminoglycans (AKA GAGs, or mucopolysaccharides) in lysosomes.The inability to break down these molecules results in a wide variety of symptoms caused by damage to several different organ … Tested Concept. In some instances, bracing Tested Concept, Thoracic curve coronal correction of > 40%, Thoracolumbar/lumbar curve coronal correction > 50%, Failure to maintain lumbar lordosis of > 45 degrees, (OBQ06.35) Karlin, The relationship between preoperative nutritional status and complications after an operation for scoliosis in patients who have cerebral palsy. 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