SCOLIOSIS, AIS

THE CRUCIAL POINT OF

TREATMENT IN
CHALLENGING MANAGEMENT
Tjuk Risantoso, MD
Orthopaedic Spine Surgeon
Spine Division
Orthopaedic and Traumatology Department
Medical Faculty - Brawijaya University
Saiful Anwar Hospital
Malang - East java
 SCOLIOSIS - AIS OUTLINES

DEFINITION
NATURAL HISTORY / PREVALENCE/ INCIDENCE/
ETIOLOGY
DIAGNOSIS

TREATMENT

COMPLICATION
 DEFINITION SCOLIOSIS - AIS

Deformity in frontal plane of the Spine

Cobb’s angle > 100

Persistent lateral curvature of the spine

Erect position
Vertebral rotation

AIS : (+) adolescent

Age : 10 y.o – 16/18 y.o
Causes : ? Unknown
 DEFINITION SCOLIOSIS - AIS

3 dimensional deformity

Sagital plane
deformation Frontal plane
Transverse plane

Cobb’s angle > 100

DEFINITION
 NATURAL HISTORY / PREVALENCE/ INCIDENCE/
ETIOLOGY
1. Scoliosis prevalence : 1- 3 % population
2. Scoliosis is divided into 2 type : Idiopathic and
Non Idiopathic
3. Idiopathic scoliosis > 80% of scoliosis
population
4. adoslecent idiopathic scoliosis (AIS) > 80 -
85% from the idiopathic scoliosis population
(89%)
5. Age > 10 y.o – 16/18 y.o
6. Right Curve > Left Curve
7. Peak High Velocity  development and
progressivity of AIS
 Predictive Progressiveness (Risk of Progressiveness)

- Age < 12 years old

- Premenarchal status
- Female > male
- Reisser (0-1)
- Peak Bone velocity TR Cartilage open /closed
- Addition value (Cobb > 25)
 NATURAL HISTORY / PREVALENCE/ INCIDENCE/
ETIOLOGY
Etiology : Unclear
- Multifactoral
- Genetics (monozygote twins > 70%, dizygote 30%)
- hormonal (melatonin and growth hormone)
- CNS/ Brain Stem/ Posterior Column  Disequilibrium
- Soft Tissues Abnormalities (muscle , ligament, disk)
- Growth and Biomechanics
- Disparity of growth
- Disproportionate anterior/posterior (anterior >
posterior)
Hauters-Volkmann postulate
 NATURAL HISTORY / PREVALENCE/ INCIDENCE/
ETIOLOGY
Etiology
 RECENT STUDIES

- Intrinsic Factor - Development

- Extrinsic Factor - Biomechanic

- CONSENSUS - Spinal Cord < N

- Bipedal  gravity pattern
- Thoracic lordosis + Vertebral
rotation
-  Convex side
-  Rib Hump

- Summerwill - Quo
e - Chue
- Dickson
 RECENT STUDIES

Summervill - Disproportionate of anterior growth

e (1952) and posterior element
- Anterior  faster than posterior 
lordosis
- Distorted (+)  rotation vertebrae 
rotational lordosis
Dickson et - Biomechanical study + Radiological
al (1984)  biplanar asimetry
Cadaveric - Children  normal  coronal plane
study asimetry + transverse plane asimetry

Many normal children 

ransverse plane asimetry +
growth  AIS
 RECENT STUDIES

Porter
- Studies 36 skeleton 40% probable IS
2000
- SC short
- Posterior element tethered
- V.B growth (+)
- Lordotic + rotate

Schmitz,
- MRI studies
2001
- MR image  do in supine
- Sagital cobb measured T4 – T12
- Group S  Sagital cobb’s 130
- Group N  Sagital cobb’s 230
- IS < N
- Relative
lordosis
 RECENT STUDIES

Casteleni - Study mathematical model +

Kouvenhovens Biomechanical study in vitro

Bipedal - Backward inclination

- Growing spine + Rotation
enhancing force
Compression Forced

Progressive deformation
(Heuters – Volkmann’s postulate)
CONSENSUS
 CONSENSUS

- Disparity of anterior growth / posterior

growth of vertebral column
GROWTH - Anterior growth – Vert. Body –
longitudinal endochondral (faster)
- Posterior Growth – Vert. Body –
Posterior
circumferential intramembranous
tethered
(slower)
- Backward inclination due to force
Buckling effect - Enhancing force (dorsally direct shear
load)
- Bipedal (erect position  axial loading +)
- Growing spine (immaturity bone)
- Long standing

Deformity progressiveness
(Heuters-Volkmann’s postulate)
 DIAGNOSIS

Diagnosis AIS - easy but management & Treatment

strategy is difficult (complex)

History
Physical Examination
Diagnosis Radiographic examination /
evaluation

Neurological examination
 DIAGNOSIS

History taking
- what - patient and family complain
- whom - deformity is detected
- where - what level
- when - age >
- why and how - treatment

Patient - doctor relationship

School screening
to screen and select cases with spinal deformity (AIS)
Controversial - Time consuming
 DIAGNOSIS
Physical Examination (PE)

STANDING lateral aspect •SD (shoulder difference)

•Arm Body distance
•Rib Hump
frontal aspect •Lumbar Hump
•Pelvic Obligity
•Skin Lession (Cafe au
lait & Harry patches
nodule)
• Breast asymmetry
• Chest asymmetry
BENDING Adam Forward Bend Test
 DIAGNOSIS
How to diagnosis scoliosis ??

deformity (+) diagnosis is easy judgement is difficult

PHYSICAL EXAMINATION
 DIAGNOSIS

Application of Scoliometer

Reference point 50 —> 110

70 —> 200

Walking Gait
Normal
Abnormal

Motor Power
 DIAGNOSIS
Radiographic Examination

1. Scoliosis Programm
- AP / lateral (standing)
- AP / Bending - supine
- Pelvic

2. Push Prone X ray

3. Traction X Ray

4. Intraoperative Traction X Ray

Better use long cassette (36’)

 How to diagnosis scoliosis ??

deformity (+) diagnosis is easy judgement is difficult

Radiographic examination

Push prone AP
Correctability
Flexibility

Fraction supine Correctability

Flexibility
Maximum correction

Curve Magnitude Cobb’s measurement

DIAGNOSIS
RADIOLOGICAL EXAMINATION

Push - Prone
 DIAGNOSIS

Traction - supine
RADIOGRAPHIC FACTOR
RADIOGRAPHIC FACTOR
DIAGNOSIS
 DIAGNOSIS
End Vertebrae (EV) Most tilted
Least rotation
Least horizontal
to where tilted
Neutral Vertebrae
1st non rotated at the caudal and cranial end of curves

Stable Vertebrae
vertebrae with in curve located by CSVL
Predictive UIV and LIV

Apical Vertebrae most horizontal

least tilted
most
rotated
 DIAGNOSIS
Long Cassette 36”

Apical Vertebrae End Vertebrae (EV)

Stable Vertebrae
Neutral Vertebrae
 DIAGNOSIS

The Aim of X Ray

- True Curve
- Structural Curve or Non Structural Curve
- Correct ability
- Flexibility
- Rigid +/-
- Risser’s sign (0-5) - skeletal maturity
 DIAGNOSIS

deformity (+) diagnosis is easy judgement is difficult

Neurological examination Left Curve

Special Case Beevor’s Sign (+)

Syringomyelia
MRI Meningomyelocele
Spina bifida
 Classification - Treatment / Management Strategy

a. Degree of Curve
b. Operative case King and Moe
Lenke
Classification - Principle basic Management / Treatment
strategy
Degree of Curve - Cobb
< 100 Observation & routine screening
100 - 200 observation & maintain + scoliosis exercise
200 - 300 scoliosis exercise + swimming
300 - 400 bracing + observation
400 - 500 bracing treatment + PE/ Swimming +
intensive observation
> 500 surgery
BRACING
BRACING
BRACING
BRACING
BRACING
BRACING
TREATMENT
Progressiveness and Management
 What the meaning of observation

- Physical examination and patient complain + clinical

+ radiographic examination
- Cooperation patient - doctor
- Progresivity +/-

Technical evaluation

- Medical advices —> Cooperative +/-

- Bracing +/- (Bracing treatment : wearing or unwearing)
- Clinical evaluation
- Radiographic examination
- Neurologic examination +/-
 Degree of Progressiveness

Degree of Progressiveness Change of Treatment Strategy

- Treatment Maintain
Observation
- Increasing of curve
magnitude per year
- Mental and Self Body Bracing
Image Want to be corrected
Pain / degenerative changes
- Complain Chest complain
- hard to breath
- dyspnoea
Peak High Velocity
 Degree of Progressiveness

Degree of Progressiveness Change of Treatment Strategy

Follow up observation:
1. routine - fail
2. > 500
3. Skeletal Maturity / Peak Bone Velocity
4. Risser
5. Progressiveness
6. Mental and Self Body image (rejection with body
contour / posture)

SURGERY
 Devices / Instrument

1960 1. Harrington
2. Luque
3. Harry - Lucky
4. TSRH/Synergy/ CD Instrument
5. Pedicle Screw Rod

Modification - Hook
- Hook wire
Hybride
- Hook Screw
sagital and coronal balance
 Surgery / surgical treatment
- Selection case
- Multiply observation / non operative
treatment (criteria / parameter)
- Non operative questionable (failed ?)

- Case assessment
Radiographic assessment

Standing / erect position

1st Casette = 36’’  long casette
Measure : • Sagittal balance
• Coronal balance
• Cobb’s angle
• Structural curve + non structural
curve
 Radiographic assessment
Special cases :
• ≥ 70°
2nd MRI • Complain (+)  pain,
effort to breath
• Left convex curve
• Neuromuscular scoliosis
• Neurologic deterioration
- Preoperative human body tolerance to operation
- Blood peripheral evaluation
- Chest spyrometri
- ECG
- Crossmatched blood test
- Preoperative additional judgement (assessment)
- Catrel traction
- Push prone radiographic
- Traction radiographic (intraoperative)
 Classification
King Moe & Lenke
Lenke , commonly used
Aim of Classification
• UIV
• LIV
• Fused/unfused segment
• Structural / unstructural
curve
 Classification

1. Level of Curve
2. Degree of Curve
3. Sagital alignment
4. Lumbar modifier
2 dimensional King and Moe 1-5
 Classification

3 dimensional Lenke classification I - VI

 Preparation
1. Human Body Tolerance for operation
- Blood checking
- Chest spyrometri Surgical
- ECG Procedure
- Crossmatched blood test 1. Incision
2. Bone graft
2. Informed consent 3. Devices
- What the name of operation 4. Placement
- Gross line surgical procedure 5. Day 1 - day 10
- Complication (Immobilization
- What the aim of operation to mobilization)
 Preparation

- less blood loss

During operation
- Stable hemodynamic

1. drug to prevent blood loss (Tranexamid acid)

2. drug to protect nerve (neuroprotectant)
3. drug to prevent infection (Antibiotics)

our teacher statement

GADO-GADO
 Technique

1. Approach : - anterior
- posterior
- combined

2. Assestment :  Open
 Closed

3. System / Instrumentation / construct used

- Distraction (single/double rod)
- Translation (Luque Rod + SW)
- Distraction + Translation H/L
- Segmental derotation :
- Hook  CD
- P/S
- Hybrid
 Technique

4. Arthrodesis / Fusion  source of graft / graft material

Post operative care  Intensive care unit

5. IOM (Intra operative Monitoring)  SSEP/MMEP

6. Bloodless technique + perfusion good

- Good assest  dissection
- Good Haemodynamic
- Less tranfusion
 Surgical technique

- Pedicle screw construct

- Free hand technique
- (Lenke)

Surgical Indication
 > 50 percent : Maturity (+)
Menarche (+) Timing
Risser ≥ 2
Peak bone level  Stop
 Progressive
 Pain
 Effort to breath (lung compliance)
 Comorbid
 COMPLICATION

EARLY
1. Bleeding
2. Infection
3. Neurologic complication

LATE
1. crankshaft phenomenon
2. coronal decompensation
 Addition of surgical therapy of AIS

The Ultimate of Scoliosis Surgical therapy

- Spinal balance (sagittal profile & coronal
balance)
- Spinal fusion (stop progressiveness)
To get it is
challenging
 The Ultimate aim of surgery

- Spinal balance
sagital
- Spinal fusion

Scoliosis3 dimensional deformity coronal

axial

- to correct coronal alignment

- to create sagital alignment
- to derotate axial
 Intraoperative monitoring

a. Monitoring of Haemodynamic (MAP)

b. Monitoring Neurological condition (SSEP &
MMEP or Wake up Test/ Staknara test)
c. Monitoring the degree of correctability
 Surgical Strategy of AIS
VS
1. Case selection
Indication : Radiographic :
- closed with parameter - Xray plain
- MRI/CT scan special
Preparation pre surgical
2. Classification
King Moe Lenke I – VI
Limited - thoracic Sagital modifier
I-V Lumbar Modifier N/-/+,
A/B/C
Da vinci
3. Approach
Anterior Posterior
Combined
UIV LIV
Uppermost Instrumented vertebrae Lowermost Instrumented vertebrae
 Surgical Strategy of AIS
VS
5. Neutral vertebrae Stable vertebrae
Apical

6. Structural vertebrae Non structural vertebrae

7. Major Minor

8. Fused segment Unfused segment

9. Conventional  New method (?) 

Concave convex = > 70%
Athrodesis  source Allograft
of graft = autograft
 Surgical Planning Strategy
- Selection case  assessment complete  till diagnosis Established
 indication surgery
 Human body tolerance to to operative workup
- Blood evaluation
- function of vital organ
- hemostatis
- ECG
- Chest Xray, chest function
 Cross – match
 Evaluation radiographic
To prevent - Long cassette 36
- AP / lateral standing (erect)
- Bending supine AP
- Rissers evaluation
- Push prone Radiography
- Traction supine radiography
To calculate + to interpolated

- Cobb degree of Classification :

curve magnitude - Approach ant/post
- -UIV, LIV
- To estimated - Apical
flexibility and - Structural/ non
correctability structural scoliosis
- Fuse/non fused …..
 Surgical Planning Strategy

- Failed Back Surgery

- Coronal decompensation
- PJK (?)

- Informed Concents
- It is mandatory to help patients understand principle of
surgical treatment scoliosis  name of operation
 Surgical Planning Strategy
Scoliosis reconstruction + posterior instrumentation (author
preferred)
- Reconstruction technique : Incision
- Distraction (H) Bone grafting  arthrodesis
- Translation (L) - source of bone graft  iliac graft (golden
- Distraction translation (H-L) standard)
- CD Instrumentation  allograft
- Pedicle Screw  bone substitution
- Iliac harvest(painful ?)
- Posterior instrumentation
- Harrington (original)
- Luque
- Harry Lucky
- CD/ CD Horizon
- TSRH
- pedicle screw Rod
- UI system (local mode)

Modification
- Hook Wire
- Hook Screw
- Screw + wire
 Post operative planning

- ICU  intensive monitoring  Vital Organ Function +

Neurological condition
- Programming bed exercise
- Day 1st – day 10th
- Day 11/12th  Bracing  mobilization starting
 SUMMARY / CONCLUSION

1. Scoliosis is the most common spinal deformity

2. Caused by Congenital, Neuromuscular and Idiopathic
3. Idiopathic scoliosis > 80% of scoliosis population,
adoslecent idiopathic scoliosis (AIS) > 80 - 85% from the
idiopathic scoliosis population (89%)
4. Diagnosis of AIS – easy by clinical, Physical examination,
Radiographic, Neurological examination but treatment /
management in challenging
5. Challenging: case per cases, asystematic assesment and
case decision selection
6. Last but not least: Preopreative judgement, preoperative
preparation confirmed to  prevent surgical complication
and poor outcome
7. Bracing treatment is modality for AIS cobb’s angle < 400,
skeletal immature, menarche (-), peak bone velocity (+) and
progressiveness prevention
 SUMARRY / CONCLUSION
8. Observation and Evaluation of Management is mandatory
case focusing to risk and curve progressiveness
9. Surgical Treatment/Management is mandatory for case
which corresponding criteria surgical indication / surgical
parameter
10.Surgical treatment is comprehensive approach with
corresponding patient, doctor, surgical equipment
11.Complication of Treatment is directly with bias of case
selection / decision and assesment and preoperative
preparation
 Scoliosis Algorithm

spinal deformity

Children adult (ASD)

deg spine

spondylolisthesis kyphosis scoliosis (1-3%) deg scoliosis

spondyl
olisthesi
- isthmic SK s
- dysplastic non idiopathic Idiopathic > 80%
canal
stenosis
neuromuscular miscellaneous Infantile juvenile adolescent adult
age

myopathic Neuropathic BMI

- syringomyelia
duchene - spina bifida
congenital
- CMT disease
- meningomyelocel
e
neurofibro - arnold chary EOS
matosis malformation ASD
AIS algoriithm
 Scoliosis Algorithm
AIS
> 80 – 90%

Etiology Natural history Definition

multifactorial - Most common (80 –
- hormonal 90%) - Lateral curvature
- CNS
- Brain stem
- Girls > boys - Cobb’s angle > 100
- > 10 years old - Vertebral rotation
- Tissue
- Peak bone
abnormalitie - Erect position
s level/velocity
- connective
- 3 dimensional deformity
tissue
disorder
- genetic
 Scoliosis Algorithm
Diagnosis

History Radiographic Physical Neurologic

taking - scoliosis Examination examination
Programm
- what - AP/lat erect to exclude NM
- whom - Bending supine scoliosis
- where R/L standing forward bending
- when - Pelvic AP Adam’s test to detected
- how
family - Push prone - PO neurologic
history - traction supine
long cassette - SD complication
- monarch 36’ - Arm Body
al status distance
- S/NS - global coronal
- seconda
- stable balance
ry sex
- neutral - C7SL (sagital
characte
- apical global hump scoliometri
ristic
- UIV/LIV balance)
- sagital - cafe au lait
modifier spot
- lumbar Harry patch
- rib lumbar 50 70
modifier nodule
- risser's - Rib hump
110 200

Diagnosis established Treatment

 Scoliosis Algorithm
Degree of Scoliosis

Cobb’s degree
Non <100 Operative
Operative
100 - 200
- observatio
n 200 - 300
- medical 300 - 400
advices
- Scoliosis
exercise borderline
- Bracing (400 - 500)
Patient –
observatio
doctor
ns relationship
progresivene
ss
 Prevalence/Incidence/Consideration/Diagnosis
Complication

early late
- Bleeding - Crankshaft
- Shock phenomenon
- Neurological - Coronal
deterioration decompensation
- Infection
THANK YOU