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SPINAL DEFORMITIE’S
BY ,
NEHA GAGGAR (MPT)
SPINAL DEFORMITYDEFINTION : any abnormality of the formation , alignment , or shape of the vertebral column .TYPES :1. Frontal plane
scoliosis 2. Sagital plane
forward head kyphosis exaggerated lordosis flat back
However SCOLIOSIS have multiplanar component : frontal sagital torsional
SCOLIOSIS
DEFINITION :Appreciable lateral deviation (>10 degrees) in the normally straight vertical line of spine.
ETIOLOGY :GeneticDisorders of bone , muscle, discDevelopmental growth abnormalitiesCentral nervous system causes
CLASSIFICATION
SCOLIOSIS
C
STRUCTURAL NONSTRUCTURAL
A.Idiopathic A.Postural Infantile(0-3yrs)
B.Compensatory juvenile (4-9yrs) C.Sciatic Adolescent (10-20 yrs)
B.CongenitalC.Neuromuscular
GRADES OF SCOLIOSIS
Grade I mild postural scoliosis
Grade II structural scoliosis with curve < 40 degrees
Grade III structural scoliosis with curve > 40 degrees
CURVE PATTERNS
1.Cervical curve : apex between C1 – C62.Cervicothoracic curve : apex is at C7, T1
3.Single major thoracic curve : Apex is between T2 – T11 4.Single major high thoracic curve : Apex from T3 with the curve extending from C7 or T1 to T4 or T5 5.Single major lumbar curve: Apex between L1-L2 and L4 6.Single major thoracolumbar curve : Apex is at T12 or L1 7.Combined thoracic & lumbar curves (double major curves) : Symmetrical double major curves 8.Double major thoracic curve : Upper thoracic from T1 to T5 or T6 and convex to the left
SCOLIOTIC CURVES
1. Compensatory curve due to primary curve
2. Compensatory curve due to deformities in other parts of the body
3. Rotational element
EVALUATION
I. INSPECTIONA.OBSERVATION
1.level of ear & contour of neck2. shoulder level3. scapular level4. position of the arms and the waist line5. back6. thorax
concave : ribs crowded & flattenedconvex : ribs apart & buldge backwards
7. hips & PSIS8. pelvis : concave : forward rotation9.knee10.feet
EVALUATION CNTD...
B. ADAMS TEST
II. EXAMINATION 1. Range of motion 2.scoliometer
EVALUATION CNTD...
3.Cobb angle measurement : The Cobb method is used to measure the degree of scoliosis
on the posteroanterior radiograph .
STEP 1 : the apical vertebra is first identified; this is the most likely displaced and rotated vertebra with the least tilted end plate.
STEP 2 : The end/transitional vertebra are then identified through the curve above and below. The end vertebra are the most superior and inferior vertebra which are least displaced and rotated and have the maximally tilted end plate.
STEP 3 : A line is drawn along the superior end plate of the superior end vertebra and a second line drawn along the inferior end plate of the inferior end vertebra.The angle between these two lines (or lines drawn perpendicular to them) is measured as the Cobb angle.
EVALUATION CNTD...
4. To check vertebral rotation : Nash and moe method, Look at the pedicles If they are equidistant from the sides of the vertebral bodies ,
no vertebral rotation (0 rotation) Grade 4 is in which the pedicle is past the center of the
vertebral body.
5. Skin marker
EVALUATION CNTD...
6.Rib Mehta’s angle(Difference at the apical rib) is of prognostic value.The RVA difference (RVAD) is the difference between the values of the RVAs on the concave and convex sides of the curve [apical vertebra]. If the convex apical rib head does not overlap the apical vertebral body, a curve with an initial RVAD of 20º or more is considered progressive.One line perpendicular to the apical vertebral endplate and another from the mid neck to the mid head of the corresponding rib.
7.MRI8.CT Myelography
MANAGEMENT
OBSERVATION
SURGERY
BRACING
PREVENTIVE ROLE
early detection
screening programme for all school children of age between 10-14 yrs
education of parents and teaching them simple observational technique
BASIC PRINCIPLES OF CORRECTION
1. ACTIVE CORRECTION :self corrective postural activities
2. PASSIVE CORRECTION :Unequal hangingAxial traction given by 2 therapists
3. MAINTENANCE OF CORRECTION :Education of patientSpinal bracing
MANAGEMENT FOR GRADE I
Re-education of bad posture monitoring after every 6 months regimen includes:
general body relaxation re-education of correct posture passive correction repeated session of maintenance of corrected posture general free mobility exercises strengthening – spinal extensors, abdominals deep breathing ex balance ex stretching of concave side avoiding activities prone to produce the deformity
MANAGEMENT FOR GRADE II
MILWAUKEE BRACEAka Cervicothoraciclumbosacral orthotic (CTLSO brace)
•Adjustable ht, can ‘grow’ with the patient•Worn 23 hrs/day•Contains pelvic attachment, thoracic pads, and chin support•Primary goal = stop progression of scoliosis•Very effective if treatment plan is followed
BOSTON BRACEAka ‘Low Profile’ Thoracolumbarsacral orthotic (TLSO)
•Primarily used for lower thoracic, thoracolumbar , & lumbar curves
•Still widely used, due to better patient acceptance than Milwaukee Brace
EXERCISE THERAPY
Goals = Improve ROM• Especially in direction of convexity• Reduce contractural change of soft tissues
on concave side
Done through:• Improve strength, endurance, & postural
control of muscles on convex side• Identify & correct vestibular and/or
proprioceptive imbalance/deficiency• Improve balance & coordination• Normalize weight bearing in lower
extremities & spine
Specific Exercises:• Stretch concave side = balance ball, hanging
from bar, leaning against wall
• Strengthen convex side = active exercise
• Strengthen trunk muscles
• Rotary torso exercises to left (right thoracic curve)
• Proprioceptive training
• Heel lift (up to 5 mm) – goal is to balance weight bearing for CNS re-education, re-evaluate every 6 weeks
•Exercises to restore cervical lordosis•Work with Exercise Ball – proprioceptive control•Sleep posture – lying on side with pillow under ribs
•To correct pelvic unleveling (ex. elevated Rt. Ilium)
• Strengthen: Lt. QL, Lt. hip adductors, Rt. G Med
• Stretch: Rt. QL, Rt. hip adductors, Lt. G Med
•Breathing exercises – maximize & normalize chest expansion
MANAGEMENT FOR GRADE III
Surgery is the treatment of choice TRACTION
NONSKELETAL SKELETAL
1.Combination of intermittent and continuous 2. Superimposition of both3. Traction of gravitational
1.Halopelvic2. halofemoral
INDICATIONS FOR SURGERY
1. Cord compression
2. Rapid progressive curve
3. Severe pain4. Respiratory impairment5. Cosmetic
AIMS OF SURGERY
1. Restore the symmetry of trunk as much as possible 2. Straighten the thoracic curve to stop decrease in
pulmonary function
PRINCIPLES OF SURGERY
I . CORRECTION OF CURVE : 1. turnbuckle cast techniques 2. distraction technique3. lessening of the curve
II. MAINTENANCE OF CORRECTION ACHIEVED 1. spinal fusion 2. spinal instrumentation
harringtons instrumentation segmental spinal instrumentation Dwyers instrumentation Zieko instrumentation
PREOPERATIVE PHYSIOTHERAPY
measurements assessment of pulmonary function muscle charting detailed neurological examination gait analysis and functional status postural guidance spinal stretching and mobility
POSTOPERATIVE PHYSIOTHERAPYFIRST 2 DAYS Respiratory status Ankle toe movements upper extremity mobilityPassive movts to lower limb turning every 2 hrly
3 RD & 4 TH DAY Active movts for lower limb measurement of curve
AFTER 5 DAYS Guidance in rolling , sitting , standing sitting chair sitting standing and walking
THANK YOU....