Slide 084 — AIS

Clean FRCS notes with inline figures

•AIS

•XR showing scoliosis, with major right thoracic curve. Apex as T8/9. Cobb angle 40 degrees

•Shoulders and pelvis level

•Truncal shift and truncal listing

•No vertebral anomalies such as hemivertebrae or unsegmented bar. Ribs also look normal.

•Risser sign 3. Triradiate cartilage status (0 vs 5 triradiate cartilage not fused at 0)

•Sagittal view to look for thoracic hypokyphosis

•Causes of scoliosis (7)

•Idiopathic

•Postural

•Compensatory (LLD)

•NM (CP)

•Syndromic (NF / marfan / OI / SED…)

•Congenital (Bar / hemivertebrae, eg VACTERL / KF)

•Pathological (Osteoblastoma)

**Fig 2.** Classification / diagrammiddle centre

•Lenke classification, King classification, Peking union medical college, Labelle 3D

•Major thoracic curve

History

•1. Birth history

•2. Developmental history

•3. FHx of scoliosis

•4. Current sx

•Age of onset and progression

•Pain or neurological sx

•Visceral problems

•5. Assess maturity: menarche, growth spurt

Further assessment

Confirm diagnosis

•Assess severity

•Estimate risk of progression

•Young presentation: age 9-13, >2y before menarche, growth rate >2cm/yr, risser 0-1, hand XR capped stage (TWIII), open triradiate cartilage

•Severity of curve

•Location of curve (Thoracic spine, double major curve)

Examination

General:

•1. body height, arm span, sitting height

•2. Cutaneous lesions

•3. Ligamentous laxity/ marfanoid features

•4. Spinal dysraphism

Standing:

•Coronal profile: Shoulder and pelvis symmetry, rib or loin hump, decompensation: truncal shift and list

•Sagittal profile: hypokyphosis / kyphoscoliosis

•Bend forward – flexibility

•Gait: scissoring gait

Sit:

•Postural scoliosis

Supine:

•Neuro exam

•Superficial abdominal reflexes

•Finish by checking maturity (secondary sexual characteristics)

Indication for MRI

•Left sided thoracic curve

•Short angular curve

•Angled kyphosis

•Neurology

•Pain

•<10yr + >20 deg

•Rapid curve progression

Management

•Goal is to stop progression and correct deformity, improve truncal balance, improve cosmesis

•Brace

•The aim of the brace is to slow down curve progression, the effect is dosage related ( >20 hr/day → success rate of 93%). Usually will keep bracing till skeletal maturity as curve progression after that will be min. (Weinstein Braist trial NEJM 2013, 72% success rate cw 48% with observation)

•Boston brace if apex below T7

•Milwaukee brace if apex above T7

•Weaning of brace at skeletal maturity (no growth in 18 months, risser 4, menarche >2yr, DR and DU physis closed) in general is done in a gradual manner, no hard science in how it should be weaned. ( e.g. spread over 4/12, stepwise  hr/day)

Surgery

Indications for surgery:

•Curves greater than 45 degrees in growing patient or >50 when growth has stopped

Aims of operation:

•Correct deformity and achieve square fusion block with <2cm listing and <20 deg tilt

•Include all structural curves while saving fusions segment

Stable fusion and prevent complications

Key elements of surgery:

Posterior approach

•Subperiosteal dissection till transverse processes

•Identify upper and lower instrumented vertebrae (ASF: end to end. PSF: proximal – end; distal Lenke I-II most distal VB touched by CVSL, III-VI distal end VB)

•Pedicle screws insertion, navigation guided

•If want to correct tilt, can fuse up or down, if want to correct truncal shift, can fuse down

•Reduction techniques: Harrington forces, cantilever bending, translation, rod rotation, direct vertebral rotation

•Insert set screw while holding the rod in place

•Decortication, bone graft to interlaminar space and into facets

•Growing rods if very immature children to prevent crankshaft phenomenon

•Continuous growth of anterior vertebrae while posterior is fused

•Leads to exaggerated lordosis and recurrence of deformity

Old implants used in scoliosis surgery:

•Harrington rod

•Luque rod

•Sublaminar wires

•Difficult to control rotation, as mainly distraction forces

•Risser sign

•I = prepubertal

•II = growth spurt

•III = decrease growth rate

•IV = variable

Disadvantage:

•Peak height velocity and 2/3 of growth spurt occurs before Risser I

•Curve not always stop at Risser IV

the screening program in HK

•Paul: 1995 start by prof luk

•3 tier system (starting in P5)

•FBT + ATR

•Scoliometer 7deg ~20deg cobbs -

•Paul: look for assymetric hump

•Hump convex side

•=/= cobb angle

•>=15, refer scoliosis center

•5-14, Moire topography → >=2 lines → XR → >20 deg → refer specialist hospital

•<5, rerefer screening program

Complications of bracing

•GI regurgitation

•Skin irritation, dermatitis or folliculitis

•Pressure

•Self esteem

Why surgery

•Natural history as outlined by Weinstein’s paper in the 1980s and early 2000s)

•Progression of curve (>50 deg → more likely SOB, >70 deg → decreased lung function, >100 deg increase risk of death)

•Increase in mortality

•Cardiopulmonary compromise

•Truncal imbalance

•Back pain

•Compare and contrast A or P fusion

•Anterior

•Adv: short segment, increase correction power by discectomy, for hypokyphosis (allow anterior column shortening)

•Disadv: difficult exposure

•Posterior

•Adv: Easy exposure

•Disadv: long segment, difficult full correction

Combined: indications

Stiff curve (>50 deg residual on FB XR)

•Severe curve (>70)

•Immature (female <10, male <13) to prevent crankshaft

#	lvl	marL	indent	logical	original note line
1	0	0	0	0	AIS
2	0	0	0	0	XR showing scoliosis, with major right thoracic curve. Apex as T8/9. Cobb angle 40 degrees
3	0	None	None	0	Shoulders and pelvis level
4	0	None	None	0	Truncal shift and truncal listing
5	0	None	None	0	No vertebral anomalies such as hemivertebrae or unsegmented bar. Ribs also look normal.
6	0	None	None	0	Risser sign 3. Triradiate cartilage status (0 vs 5 triradiate cartilage not fused at 0)
7	0	None	None	0	Sagittal view to look for thoracic hypokyphosis
8	0	None	None	0	Causes of scoliosis (7)
9	0	228600	-228600	1	Idiopathic
10	0	228600	-228600	1	Postural
11	0	228600	-228600	1	Compensatory (LLD)
12	0	228600	-228600	1	NM (CP)
13	0	228600	-228600	1	Syndromic (NF / marfan / OI / SED…)
14	0	228600	-228600	1	Congenital (Bar / hemivertebrae, eg VACTERL / KF)
15	0	228600	-228600	1	Pathological (Osteoblastoma)
16	0	None	None	0	Lenke classification, King classification, Peking union medical college, Labelle 3D
17	0	None	None	0	Major thoracic curve
18	0	None	None	0	Hx:
19	0	None	None	0	1. Birth history
20	0	None	None	0	2. Developmental history
21	0	None	None	0	3. FHx of scoliosis
22	0	None	None	0	4. Current sx
23	0	171450	-171450	1	Age of onset and progression
24	0	171450	-171450	1	Pain or neurological sx
25	0	171450	-171450	1	Visceral problems
26	0	None	None	0	5. Assess maturity: menarche, growth spurt
27	0	None	None	0	Further assessment
28	0	228600	-228600	1	Confirm diagnosis
29	0	228600	-228600	1	Assess severity
30	0	228600	-228600	1	Estimate risk of progression
31	1	685800	-228600	2	Young presentation: age 9-13, >2y before menarche, growth rate >2cm/yr, risser 0-1, hand XR capped stage (TWIII), open triradiate cartilage
32	1	685800	-228600	2	Severity of curve
33	1	685800	-228600	2	Location of curve (Thoracic spine, double major curve)
34	0	None	None	0	PE:
35	0	None	None	0	General:
36	0	None	None	0	1. body height, arm span, sitting height
37	0	None	None	0	2. Cutaneous lesions
38	0	None	None	0	3. Ligamentous laxity/ marfanoid features
39	0	None	None	0	4. Spinal dysraphism
40	0	None	None	0	Standing:
41	0	228600	-228600	1	Coronal profile: Shoulder and pelvis symmetry, rib or loin hump, decompensation: truncal shift and list
42	0	228600	-228600	1	Sagittal profile: hypokyphosis / kyphoscoliosis
43	0	228600	-228600	1	Bend forward – flexibility
44	0	228600	-228600	1	Gait: scissoring gait
45	0	0	0	0	Sit:
46	0	0	0	0	Postural scoliosis
47	0	0	0	0	Supine:
48	0	0	0	0	Neuro exam
49	0	0	0	0	Superficial abdominal reflexes
50	0	0	0	0	Finish by checking maturity (secondary sexual characteristics)
51	0	0	0	0	Indication for MRI
52	1	685800	-228600	2	Left sided thoracic curve
53	1	685800	-228600	2	Short angular curve
54	1	685800	-228600	2	Angled kyphosis
55	1	685800	-228600	2	Neurology
56	1	685800	-228600	2	Pain
57	1	685800	-228600	2	<10yr + >20 deg
58	1	685800	-228600	2	Rapid curve progression
59	0	None	None	0	Mx:
60	0	None	None	0	Goal is to stop progression and correct deformity, improve truncal balance, improve cosmesis
61	0	None	None	0	Brace
62	0	None	None	0	The aim of the brace is to slow down curve progression, the effect is dosage related ( >20 hr/day → success rate of 93%). Usually will keep bracing till skeletal maturity as curve progression after that will be min. (Weinstein Braist trial NEJM 2013, 72% success rate cw 48% with observation)
63	1	None	None	1	Boston brace if apex below T7
64	1	None	None	1	Milwaukee brace if apex above T7
65	0	None	None	0	Weaning of brace at skeletal maturity (no growth in 18 months, risser 4, menarche >2yr, DR and DU physis closed) in general is done in a gradual manner, no hard science in how it should be weaned. ( e.g. spread over 4/12, stepwise  hr/day)
66	0	None	None	0	Surgery
67	0	None	None	0	Indications for surgery:
68	0	None	None	0	Curves greater than 45 degrees in growing patient or >50 when growth has stopped
69	0	None	None	0	Aims of operation:
70	0	228600	-228600	1	Correct deformity and achieve square fusion block with <2cm listing and <20 deg tilt
71	0	228600	-228600	1	Include all structural curves while saving fusions segment
72	0	228600	-228600	1	Stable fusion and prevent complications
73	0	0	0	0	Key elements of surgery:
74	0	171450	-171450	1	Posterior approach
75	0	171450	-171450	1	Subperiosteal dissection till transverse processes
76	0	171450	-171450	1	Identify upper and lower instrumented vertebrae (ASF: end to end. PSF: proximal – end; distal Lenke I-II most distal VB touched by CVSL, III-VI distal end VB)
77	0	171450	-171450	1	Pedicle screws insertion, navigation guided
78	0	171450	-171450	1	If want to correct tilt, can fuse up or down, if want to correct truncal shift, can fuse down
79	0	171450	-171450	1	Reduction techniques: Harrington forces, cantilever bending, translation, rod rotation, direct vertebral rotation
80	0	171450	-171450	1	Insert set screw while holding the rod in place
81	0	171450	-171450	1	Decortication, bone graft to interlaminar space and into facets
82	0	None	None	0	Growing rods if very immature children to prevent crankshaft phenomenon
83	0	None	None	0	Continuous growth of anterior vertebrae while posterior is fused
84	0	None	None	0	Leads to exaggerated lordosis and recurrence of deformity
85	0	None	None	0	Old implants used in scoliosis surgery:
86	0	171450	-171450	1	Harrington rod
87	0	171450	-171450	1	Luque rod
88	0	171450	-171450	1	Sublaminar wires
89	0	0	0	0	Difficult to control rotation, as mainly distraction forces
90	0	None	None	0	==================
91	0	None	None	0	Risser sign
92	1	None	None	1	I = prepubertal
93	1	None	None	1	II = growth spurt
94	1	None	None	1	III = decrease growth rate
95	1	None	None	1	IV = variable
96	0	None	None	0	Disadvantage:
97	0	171450	-171450	1	Peak height velocity and 2/3 of growth spurt occurs before Risser I
98	0	171450	-171450	1	Curve not always stop at Risser IV
99	0	None	None	0	Tell me about the screening program in HK
100	0	None	None	0	Paul: 1995 start by prof luk
101	0	None	None	0	3 tier system (starting in P5)
102	0	0	0	0	FBT + ATR
103	0	0	0	0	Scoliometer 7deg ~20deg cobbs -
104	0	0	0	0	Paul: look for assymetric hump
105	0	0	0	0	Hump convex side
106	0	0	0	0	=/= cobb angle
107	0	171450	-171450	1	>=15, refer scoliosis center
108	0	171450	-171450	1	5-14, Moire topography → >=2 lines → XR → >20 deg → refer specialist hospital
109	0	171450	-171450	1	<5, rerefer screening program
110	0	0	0	0	Complications of bracing
111	0	171450	-171450	1	GI regurgitation
112	0	171450	-171450	1	Skin irritation, dermatitis or folliculitis
113	0	171450	-171450	1	Pressure
114	0	171450	-171450	1	Self esteem
115	0	0	0	0	Why surgery
116	0	0	0	0	Natural history as outlined by Weinstein’s paper in the 1980s and early 2000s)
117	0	171450	-171450	1	Progression of curve (>50 deg → more likely SOB, >70 deg → decreased lung function, >100 deg increase risk of death)
118	0	171450	-171450	1	Increase in mortality
119	0	171450	-171450	1	Cardiopulmonary compromise
120	0	171450	-171450	1	Truncal imbalance
121	0	171450	-171450	1	Back pain
122	0	0	0	0	Compare and contrast A or P fusion
123	0	0	0	0	Anterior
124	0	0	0	0	Adv: short segment, increase correction power by discectomy, for hypokyphosis (allow anterior column shortening)
125	0	0	0	0	Disadv: difficult exposure
126	0	0	0	0	Posterior
127	0	0	0	0	Adv: Easy exposure
128	0	0	0	0	Disadv: long segment, difficult full correction
129	0	0	0	0	Combined: indications
130	0	228600	-228600	1	Stiff curve (>50 deg residual on FB XR)
131	0	228600	-228600	1	Severe curve (>70)
132	0	228600	-228600	1	Immature (female <10, male <13) to prevent crankshaft

084. AIS