Bitan FD, Neuwirth MG, Kuflik PL, Casden A, Bloom N, Siddiqui S 2002 The use of short and rigid anterior instrumentation in the treatment of idiopathic thoracolumbar scoliosis: a retrosp
Trang 1Treatment Treatment of infantile and juvenile
sco-liosis remains a therapeutic challenge because of
the adverse effects of multisegmental fusion in a
growing spine If conservative treatment (cast,
braces) has failed to control the curve, spinal
instru-mentation without fusion becomes necessary
Sur-gery for these curve types is very demanding and
prone to complications often requiring revision
sur-gery.
The natural history of adolescent idiopathic
scoli-osis is benign without significant differences to an
asymptomatic control group regarding physical
functioning and quality of life in adulthood The
treatment depends on the severity of the curve and
the risk of progression Conservative treatment is
intended to control progression of smaller curves It
consists of observation and physiotherapy in
curves less than 10°–25° in skeletally immature
patients Curves of 25° – 40° are usually treated by
bracing Braces are only effective before skeletal
maturity is reached Surgery is indicated in curves
larger than 40° – 50° or rapidly progressing curves
despite conservative treatment The objective of
scoliosis surgery is to stop the progression and to
correct the deformity Posterior instrumentation
and fusion remains the gold standard and allows
for a correction of the coronal deformity with
resto-ration of the coronal and sagittal balance and
pro-file Today, pedicle screws are frequently used as they allow a better correction and shorter fusion length than systems only using hooks and wires In skeletally immature patients an anterior release and fusion is necessary to avoid further anterior growth after posterior fusion with a deterioration of
the deformity (crankshaft phenomenon) The more demanding anterior scoliosis surgery often
allows motion segments to be spared and vertebral rotation to be better addressed.
In contrast to adolescent scoliosis, adult idiopathic scoliosis patients often present with symptoms
(pain, neurological deficits) due to secondary degenerative changes Surgical decision-making in adult idiopathic scoliosis strongly depends on the underlying causes of the pain or neurological defi-cits The goal in adult scoliosis is to achieve a bal-anced spine without pain or neurological deficits.
Decompression of a nerve root compression or sec-ondary central stenosis is possible in selected patients with a balanced spine Fusion in situ (w/o short-segmental instrumentation) should be added when extensive decompression is needed to avoid curve deterioration The treatment of an imbalanced spine with secondary degenerative changes often requires extensive posterior release and in some cases necessitates multiple spinal osteotomies.
Key Articles
Nachemson A ( 1968) A long term follow-up study of non-treated scoliosis Acta Orthop
Scand 39:466–476
This is one of the first long-term follow-up studies on the natural course of scoliosis
Dif-ferent types of scoliosis are included For congenital, thoracogenic and neurogenic
scolio-sis prognoscolio-sis was found to be worse than for idiopathic, rachitogenic and poliomyelitic
scoliosis
Weinstein SL, Zavala DC, Ponseti IV ( 1981) Idiopathic scoliosis: long-term follow-up
and prognosis in untreated patients J Bone Joint Surg Am 63:702–712
Thoracic curves of 50°–80° were found to be at a high risk of progressing even after
skele-tal maturity was reached Curves smaller than 30° did not progress regardless of the curve
pattern In thoracic curves, the Cobb angle and vertebral rotation were found to be
important risk factors for curve progression
Lonstein JE, Carlson JM ( 1984) The prediction of curve progression in untreated
idio-pathic scoliosis during growth J Bone Joint Surg Am 66:1061–1071
In this study of patients with mild idiopathic scoliosis, pattern and magnitude of the
curve, the patient’s age at first diagnosis, menarchal status and the Risser sign were found
to be related to curve progression during growth
Harrington PR ( 1962) Treatment of scoliosis Correction and internal fixation by spine
instrumentation J Bone Joint Surg 44A:591–610
Historical paper on spinal instrumentation for scoliosis describing the technique of
scoli-osis correction by distraction
Trang 2Cotrel Y, Dubousset J ( 1984) A new technique for segmental spinal osteosynthesis using the posterior approach Rev Chir Orthop Reparatrice Appar Mot 70:489–494
Cotrel and Dubousset describe their technique for the posterior segmental derotation technique of scoliosis correction
Dubousset J, Herring JA, Shufflebarger H ( 1989) The crankshaft phenomenon J Pediatr Orthopedics 9:541–550
This article first describes the progression of the anterior column deformity despite pos-terior instrumentation and solid fusion, the so-called crankshaft phenomenon
King HA, Moe JH, Bradford DS, Winter RB ( 1983) The selection of fusion levels in tho-racic idiopathic scoliosis J Bone Joint Surg Am 65:1302–1313
Landmark paper on the classification of thoracic curves into five types
Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K ( 2001) Ado-lescent idiopathic scoliosis: a new classification to determine extent of spinal arthrode-sis J Bone Joint Surg 83A:1169–1181
The King classification only included thoracic curves Lenke et al therefore developed a new more comprehensive classification system It allows the classification of 42 different curve patterns including all curve types and the thoracic sagittal profile This classifica-tion is helpful for the selecclassifica-tion of fusion levels
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