2/18/2016 Scoliosis and Kyphosis: An Update on Diagnosis and Management Lloyd A. Hey M.D., M.S Hey Clinic for Scoliosis and Spine Surgery http://www.heyclinic.com [email protected] 2 Learning Objectives: To learn proper screening techniques for diagnosing spinal deformities Understand proper conservative management for patients with deformity. To be able to quickly identify the five “red flag signs” in spinal patients that may indicate an urgent spine problem. Disclosures: • I have no disclosures SPINAL DEFORMITY: IT’S NOT JUST COSMETIC. CAN CAUSE LONG-TERM SUFFERING Case Report, 34 AD (2000 yrs ago) “On a Sabbath Jesus was teaching in one of the synagogues, and a woman was there who had been crippled by a spirit for eighteen years. She was bent over and could not straighten up at all. When Jesus saw her, he called her forward and said to her, “Woman, you are set free from your infirmity.” Then he put his hands on her, and immediately she straightened up and praised God.” Bible, NIV Luke 13:10-13 1 2/18/2016 My own suffering and healing experience: In 1978, a compassionate team, including Dr. Mark Pittman, and Barbara Bader, PT, saved my life, my sanity, my badly broken leg, and inspired me to serve too, using compassion + engineering to help patients Barbara Bader, PT 5 1980-84: MIT Engineering, 84-88 Harvard Med 1989-1994: Harvard Residency, Boston Children’s Hospital Inspired and Trained by Dr. John Hall who put metal frames on the INSIDE to work miracles to straighten children. 2008 Dr. Hey & Dr. John Hall Vision: Life-Long Spinal Deformity Care 1994: Duke Spine Fellowship 1995-2004: Duke Faculty 2005-Current: Hey Clinic for Scoliosis and Spine Surgery From Patient with “frame on outside” my leg 6 To Engineer, designing frames, cartilage research To Scoliosis Surgeon, helping children and adults with “frames on the inside” Always seeking to work as catalyst building, serving with, and learning from the team: To serve well, and improve care over time. 2 2/18/2016 Types of Spinal Deformity 7 Scoliosis Lateral curvature of the spine Kyphosis Exaggeration of normal curvature of thoracic spine Spondylolisthesis Slippage of one vertebra on the other, either forwards or backwards. 8 Why does Spinal Deformity Matter? Can impact quality of life with limited activity, pain, disability, reduced respiratory function or diminished self- esteem. THINK LIFE-LONG. Emphasis on Prevention of future suffering Scoliosis Causes: Idiopathic, Congenital, Neurologic (cerebral palsy, neuro- muscular) Complex genetic connection: Females are 8 times more likely to progress to curve magnitude that requires treatment. Fathers with scoliosis more likely to pass on scoliosis to children. Genetic Tests Ineffective. 3 2/18/2016 10 Screening for Scoliosis: Physical Exam Signs Thoracic rib or lumbar Shoulder hump Trunk Shift Asymmetry Scoliometer Check Thoracic and Lumbar Areas Scoliometer or App for iPhone: Scoliometer reading over 5 degrees X-Ray Indicated. Bunnell WP The Journal of Bone and Joint Surgery. American Volume [1984, 66(9):1381-7] Spinal Deformity Screening in Adults Degenerative scoliosis is common – 30% older adult pop. Low back pain w/ scoliosis treated conservatively like other patients. “Stable” curves can become unstable, or more rapidly progressive in later adulthood w/ degenerative collapse Height and X-Ray measurements over time very helpful Deformity after fractures. Deformity above / below old spinal fusions. Flatback. AVOID SCOLIOSIS MISNOMER #1: YOU ARE DONE GROWING SO YOU DON’T HAVE TO WORRY ABOUT CURVE PROGRESSION 4 2/18/2016 Treatment, including bracing Growing child, adolescent: <25 degrees – observe (every 4-6 months when growing) 25-30 degrees – consider bracing if curve progressive and still growing 30-39 degrees – consider bracing even first visit, if growth remaining. 40 degrees or more: surgery usually. Bracing requires longer discussion, considering whole patient and family: compliance an issue. In Adults, continue to monitor curve each year through age 25, and after each pregnancy. Older patients can be monitored every 2-5 years. 14 Conservative Treatment Includes: Physical Therapy Including core strengthening for low back pain Low impact aerobic exercise Healthy Weight For every 1 lb overweight someone is, there is an additional 5 lbs on the low back! NSAIDS Light weight low back brace Follow-up to check for progression of deformity “We conducted the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) to determine the effectiveness of bracing, as compared with observation, in preventing progression of the curve to 50 degrees or more (a common indication for surgery)…. The primary outcome was determined when the first of two conditions was met: curve progression to 50 degrees or more (treatment failure) or skeletal maturity without this degree of curve progression (treatment success)…. 1,086 met criteria, only willing to be 116 randomized, 126 preference The rate of treatment success was 72% in the bracing group and 48% in the observation group … 5 2/18/2016 Years of being out of alignment can wear out “Goodyear” discs. Early Realignment can prevent that destruction Disc damage starts during …which can help prevent this adolescence, but is reversible disabling outcome 10-60+ years with surgical realignment… later. Result: Pain, quality of life, disability, and need for larger / more risky surgery Potential for decreased pulmonary function. Posture Self image issues 17 Surgical Correction: Adolescents 18 Surgical Correction: Adults Due to the degeneration in the lower back, a longer fusion is required than the adolescent with the same curve. 6 2/18/2016 19 Case Presentation: You have patient that had a Harrington Rod placement in their teens. They are now complaining of increased difficulty standing up straight, walking, and increasing low back pain. The x-rays show all hardware is in good position. What is your differential diagnosis? 20 Flat back syndrome or failure below the fusion is one of conditions we are now treating for prior Harrington Rod/earlier scoliosis constructs. Most patients are middle-aged who had surgery in their teens/20’s for their scoliosis. The constructs for these fusions were straight rods, without any kyphosis/lordosis curves, so it puts lots of pressure on the area below the fusion, which most of the time ends in the middle of the lordosis. This can be treated by extending the fusion and giving the proper lordosis in the lower back. Patients pain and posture is greatly relieved. Kyphosis –Not Always Just “Bad Posture” Exaggerated curve that causes a rounded shoulder or hunched back Normal kyphosis : 30-45 deg. > 60 deg may become symptomatic > 70 consider surgery Often associated with lower back and neck pain Is followed like scoliosis Can be post-traumatic, or postop complication (proximal junctional kyphosis) 7 2/18/2016 22 Types of Kyphosis: Post-Traumatic Likely due to a fracture Post-Surgical Proximal Junctional Kyphosis (PJK) or Proximal Junctional Failure (PJF) Scheuermann’s Due to growth plate abnormality Degenerative Osteoporosis causing compression fractures Spondylolisthesis • Slippage of one vertebra on another (side, front, back) • Can be genetic, result of a pars fracture or due to disc degeneration • Pars fractures are painful and can cause lots of pain- seen in gymnasts and catchers in baseball frequently. • Increased risk for stenosis (nerve pinch) with these 24 Spondylolisthesis Monitoring and Treatment Important to follow regularly, especially if a pars fracture is etiology because high risk of progression. Can brace, with light weight or custom molded low back brace. Will not correct deformity, but can help symptomatically. Surgery is considered if the slippage is progressive, causing significant pain or a nerve pinch. 8 2/18/2016 25 26 Emergency Signs/Symptoms No matter what spine condition you encounter, the following are “red flag signs” and could be an indicator of a spinal cord or significant nerve pinch: Loss of bowel or bladder function Progressive pain Progressive Weakness Progressive Clumsiness Progressive Numbness The simple adolescent idiopathic scoliosis/ kyphosis patient: Think like an engineer: postop sports? 9 2/18/2016 Playing sports after scoliosis surgery? 12 yo volley ball player with 57 degree preop, 2yrs out 16 yo golfer from FL put off surgery due to pro golf concerns 10 2/18/2016 Can I bend after scoliosis surgery? 11 2/18/2016 Lifelong spine deformity care benefits 37 years later, still learning, still “tinkering” innovating, working with the team Compassion empowering everything we do. Treat others the way we would (or have!) been treated. Still enjoy improving “Craftsmanship” Every Error is a chance to Learn, and then Improve/Innovate. Special people we work and serve with increases the joy as we serve and learn together, and have team wins. Summary and Quiz!! 36 Thank you…..Questions?? Contact Information: Lloyd A. Hey M.D., M.S. Hey Clinic for Scoliosis and Spine Surgery http://www.heyclinic.com [email protected] Rachel Griffin, PA-C (919) 279-3556 (cell) [email protected] 12.