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Spine deformities recognition and evaluation

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Spine deformities recognition and evaluation

  1. 1. Spine Deformities Recognition and Evaluation Dr. Bahaa Ali Kornah Prof.. Of Orthopedic Al-Azhar University Cairo - Egypt bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  2. 2. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT Dr. Bahaa Ali Kornah Prof.. Of Orthopedic Al-Azhar University Cairo - Egypt ‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬
  3. 3. Deformities • Types • Static • Progressive bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  4. 4. Deformities • Site at Bone short bone Bending Mal - Alignments Joints defect articular surface ligaments laxity osteoligamentous structures bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  5. 5. Deformities • Postural deformities Deformity correct by voluntary effort • Structural deformity Deformity can not correct by voluntary effort due to anatomical structures changes + progressive • Fixed deformity Joint is deformed and immobile • bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  6. 6. Adult Spinal Deformity Quality of Life Affected Functional limitations Increased pain Use of analgesics Baldus et al. Spine 2008 bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  7. 7. Adult Spinal Deformity Psychological Effect Social Stigma Depression Anxiety Beven et al. Spine, 2003 bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  8. 8. Spinal Deformity • Coronal plan • Sagittal plane • Axilla plane bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  9. 9. • Ideal spinal alignment allows a standing posture with minimal muscular energy expenditure. • This is accomplished through a complex relationship between the 1. physiologic curvatures of the spine, 2. the morphology of the pelvis, and 3. the musculature of the axial and appendicular skeleton. (Schwab F, et al. Spine2010) (Bhalla A, et al. Seminars in Spine Surgery 2015) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  10. 10. NORMAL SPINE ALLIGNMENT  FRONTAL PLANE =CORONAL STRAIGHT  LATERAL PLANE= SAGITTAL – Cervical lordosis (≈30°) – Thoracic kyphosis (10°-40°) – Lumbar lordosis (40°-60°) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  11. 11. • C7 – Prom. Spinous Process  T3- Level with Medial Scapular Spine  T7 – Inferior angle of scapula  L2 – Lowest Rib  L4 – Iliac Crestbahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  12. 12. Gravity line of human body AND the plumb line, bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  13. 13. Postural Alignment • 2 naturally occurring curves – LORDOTIC (in lumbar region) – KYPHOTIC (in upper thoracic lower cervical regions) – Abnormalities -- accentuated vertebral curves bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  14. 14. CSVL= central sacral vertical line bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  15. 15. Spinal Deformity  Sagittal plane deformity  Coronal plane deformity  Axial plane deformity  Spinopelvic balance • Uniplanar + in one direction • Two planer deformity • Rotational deformity • Combined bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  16. 16. Spinal Deformity  Scoliosis  3-dimensional deformity affecting all 3 planes  Can be difficult to visualize with 2-dimensional radiographs  Kyphosis  Deformity affecting the sagittal plane  Neuromuscular  Results from neurologic or muscular diseases, such as cerebral palsy, muscular dystrophy, or polio bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  17. 17. Types of Deformity  Congenital  Idiopathic (80%)  Infantile (0-2 y)  Juvenile (3-9 y)  Adolescent (10-17 y)  Adult (>18 yo)  Neuromuscular (CP, DMD, SMA etc..)  Degenerative  Traumatic / infectious  Iatrogenic  Syndromic (ED, Marfans, PW, Down S etc.) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  18. 18. • Adult spinal deformity (ASD) resulting in coronal and/or sagittal plane decompensation. – idiopathic scoliosis – de novo or degenerative curves (Savage JW, et al. Global Spine J 2014) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  19. 19. SPINAL DEFORMITY IN ADULTS • CLINICAL PRESENTATION  PAIN  COSMETIC DEFORMITY  NEUROLOGIC SYMPTOMS  PULMONARY COMPROMISE  PROGRESSION bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  20. 20. DEFORMITY Clinical Radiology bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  21. 21. Evaluation of patient with ASD Clinical examination of spine bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  22. 22. Cervical (Lordosis) Thoracic (Kyphosis) Lumbar (Lordosis) Front Side bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  23. 23. A. Physical: • Posture: » Splinting » Body language • Gait: » Antalgia » Heel / Toe pattern » Trendelenburg • Musculoskeletal: » ROM » Leg length » Vascular » Atrophy bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  24. 24. • Back: » Inspection » Palpation » ROM » Scoliosis • Neurological: » Sensation » Motor » DTRs • Abdomen: » Presence of masses • Rectal if indicated: » Evaluation of sphincter tone bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  25. 25. Gait bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  26. 26. Inspection Standing (a) Look from the side i. normal spine > cervical lordosis > thoracic kyphosis > lumbar lordosis bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  27. 27. • Kyphos and kyphosis • A Kyphosis is a posterior convexity of the spinal column • Smooth = round back • Or • Angular bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  28. 28. •Smooth = round back  senile kyphosis (with osteoporosis, osteomalacia or pathological fracture)  Scheuermann’s disease (osteochondritis involving one or more of the vertebrae)  ankylosing spondylitis bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  29. 29. Kyphosis bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  30. 30. Angular Gibbus (angular kyphosis)  fracture  tuberculosis of the spine  congenital abnormality bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  31. 31. Thoracic Kyphosis • exaggerated thoracic curve • occurs more frequently than lordosis • mechanism -- vertebra becomes wedge shaped • causes a person to “hunch over” bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  32. 32. Kyphosis • aka “Swimmer’s Back” • develops in children swimmers who train with an excessive amount of butterfly • also seen in elderly women suffering from osteoporosis bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  33. 33. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  34. 34. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  35. 35. • Lordosis • A lordosis is a posterior concavity of the spinal column, often in the lumbar region. • Spondylolisthesis. • Pregnancy • Compensatory lordosis may be necessary to maintain balance. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  36. 36. . Lumbar curvature >flattening or reversal of lumbar lordosis : prolapsed intervertebral disc osteoarthritis of the spine infection of vertebral bodies ankylosing spondylitis >increase in lumbar lordosis may be normal (esp. in pregnant women) spondylolisthesis secondary to increased thoracic curvature or to flexion deformity of the hips bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  37. 37. Lumbar Lordosis • exaggeration of the lumbar curve • associated w/weakened abdominals (relative to extensors) • characterized by low back pain • prevalent in gymnasts, figure skaters, swimmers (flyers) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  38. 38. Look from behind = posterior i.listing of trunk (due to muscle spasm) ii.Scoliosis (lateral curvature of spine) - postural : scoliosis disappears with forward flexion of the spine - structural : scoliosis persists with forward flexion of the spine and a rib hump presents iii.Shoulder tilt iv.Pelvic tilt bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  39. 39. v. Skin changes over the spine - hair tuft (spina bifida) - sinus - color changes or pigmentation (neurofibroma) - scar vi.Swelling vii.Prominent crease of the trunk viii.Wasting of paraspinal muscles, glutei, hamstrings and calf muscles bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  40. 40. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  41. 41. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  42. 42. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  43. 43. Scoliosis . bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  44. 44. Scoliosis • lateral deviation of the spinal column • can be a ‘C’ or ‘S’ shape • involves the thoracic and/or lumbar regions • associated w/disease, leg length abnormalities, muscular imbalances bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  45. 45. Scoliosis • more prevalent in females • cases range from mild to severe – small deviations may result from repeated unilateral loading (e.g. carrying books on one shoulder) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  46. 46. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  47. 47. Saggital Imbalance bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  48. 48. • Feel= Palpation • In the midline and laterally. • The vertebral spinous processes • Interspinal ligaments • The muscles on each side of the spine should also be palpated for spasm. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  49. 49. Palpation bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  50. 50. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  51. 51. 3.SWELLING- Spina bifida-meningocele in the sacral or occipital region Congenital sacrococcygeal teratoma in sacrococcygeal region bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  52. 52. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  53. 53. MEASUREME NTS1. Linear measurements a.From external occipital protrubence to tip of coccyx b. Iliocostal distance ( tip off last rib to iliac cest) c.Segmental measurement d. Acromiooccipital distance e.Schober`s test f. Otto test 2. Chest expansion 3. Limb length discrepancybahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  54. 54.  Thoracic and lumbar spine  Forward flexion (Schober’s test) Normal : 90 degrees  Extension Normal : 30 degrees  Lateral flexion to left and right Normal : 30 to 45 degrees  Rotation to left and right Normal : 45 degrees bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  55. 55. • NEUROLOGICAL EXAMINATION bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  56. 56. Cone of economy: • Increasing positive sagittal imbalance causes – a position toward the periphery of the cone – increased muscular effort and energy expenditure – causing pain, fatigue, and disability • If the body is shifted beyond the periphery of the cone, external supports are needed: – a cane, crutch, or walker The Dubousset cone of economy concept is important in maintaining upright posture minimized energy expenditure with standing and walking bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  57. 57. Concept of cone of economy • Management of spinal deformity includes the recognition and treatment of scoliotic, kyphotic, and spondylolisthetic conditions. • Several radiographic measures have been defined for the assessment of spinal alignment, including coronal, sagittal, and pelvic measures. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  58. 58. Deviation in coronal direction Scoliosis Def. Lat. deviation of the spine from midline with rotation bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  59. 59. Deviation in sagittal direction • Lordosis • kyphosis bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  60. 60. Radiographic Evaluation • In the radiographic assessment we need – a standard full-length (36-inch) posterior-anterior and lateral spine x- rays – the hips and the knees fully extended • For the lateral radiographs – elbows and wrists should be fully flexed – hands in a fist – the proximal interphalangeal joints placed into the supraclavicular fossa – With no external supports • In Hyperextension films – a bolster placed at the apex of the deformity – prone and supine images (Horton WC, et al. Spine 2005) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  61. 61. Sagittal plane analysis: Full length AP and lateral views: • Hips and knees are fully extended. • Elbows and wrists are fully flexed. • Hands in the supra clavicular fossa. • . New system radiography EOS X-ray system (Nobel prize-winning) allowing 2D to 3D reconstructions from biplanar X-ray images (EOS Imaging, Paris, France) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  62. 62. Regional Parameters A. Thoracic Kyphosis B. Thoraco-Lumbar C. Lumbar Lordosis Radiographic Evaluation A B C7 T1 Regional Parameters Global Alignment Pelvic Parameters A C B T1 C Global Alignment A. SVA (Sagittal vertical axis) B. T1-SPI (T1 & T9 sagittal tilt) C. TPA (T1 pelvic angle) D. Proximal thoracic slope Pelvic Parameters A. Pelvic Incidence B. Sacral Slope C. Pelvic Tilt bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  63. 63. Regional Parameters Sagittal balance • Sagittal balance: is the balance between the normal sagittal curves of the spine to center the head on the pelvis with the least energy expenditure. • Regional sagittal alignment is assessed by; Cervical lordosis (≈30°) Thoracic kyphosis (10°-40°) Lumbar lordosis (40°-60°) These curves should balance the occiput over the sacropelvic axis. • Hips and Knees share spine and pelvis in sagittal balance control. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  64. 64. Global Sagittal Alignment Radiological Evaluation: A) Sagittal vertical axis (plumb line): • From center of C7 downwards. • Normally within 0.5 cm from the postero-superior aspect of S1. • Offset >2.5-4 cm ant. Or post is abnormal. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  65. 65. Global Sagittal Alignment B) T1-SPI (T1 & T9 sagittal tilt) T1 spinopelvic inclination bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  66. 66. Global Sagittal Alignment • T1 spinopelvic inclination (T1-SPI) – T1 or T9 sagittal tilt is the angle subtended by a vertical plumb line from the center of the T1 or T9 vertebral body and a line drawn to the bicoxofemoral axis. • There is a correlation between T1-SPI and patient self reported function – with SRS, ODI, and SF-12 assessments of HRQOL • T1-SPI is superior to the SVA – does not differentiate between compensated offset of the upper thoracic spine and deformity with pelvic retroversion. • T9-SPI can be used, with the added benefit of greater visibility on radiographs as compared to T1 (Lafage V, et al. Spine 2009) (Lafage, V, et al. Spine 2008) (Schwab F, et al. Spine 2009) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  67. 67. Global Sagittal Alignment C) TPA (T1 pelvic angle) • T1 pelvic angle (TPA) is a novel parameter showing both trunk inclination and pelvic retroversion. – TPA is the angle between the line from the femoral head axis to the centroid of T1 and the line from the femoral head axis to the middle of the S1 endplate. • Increasing values of TPA have been correlated with worse health outcome measures. • TPA can be measured intraoperatively with the patient in the prone position. • The severe deformity threshold for TPA was determined to be 20° (ODI > 40) – 4.1° (ODI change = 15) (Ryan DJ, et al. Spine 2014) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  68. 68. Global Sagittal Alignment D)Proximal thoracic slope bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT 25 DEGREE
  69. 69. Pelvic Parameters Sacropelvic parameters: • Pelvic incidence: (50°-60°) non positional parameter. morphological parameter. line perpendicular to sacral plate at its midpoint and a line to axis of rotation of femoral head. • Sacral slope : (40°-50°) positional parameter. compensatory parameter. superior end plate of S1 and a horizontal line. • Pelvic tilt angle : (10°-20°) positional parameter. compensatory parameter. mid point of sacral plate to femoral rotational axis and a vertical line. The pelvic incidence is equal to the arithmetic sum of the sacral slope and the pelvic tilt (PI = PT + SS). Legaye J, et al. Eur Spine J 1998) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  70. 70. Pelvic Parameters Sacropelvic parameters: • Position of pelvis plays an important role in upright sitting and standing postures. • Pelvic incidence is constant and specific to each individual, and is independent of the spatial orientation of the pelvis. – (PI = PT + SS) – LL = PI +/- 9 ° • PT and SS are dynamic pelvic parameters. • PT is correlated with increased pain and disability. (Lafage, V, et al. Spine 2008) (Le Huec JC, et al. International Orthopedics 2015) (PI = 52° ± 10°) (PT = 15° ± 7°) (SS = 30° ± 9°) (Lafage V, et al. Spine 2009) (D. Deinlein et al. Spine Deformity 2013) (Labelle H, et al. Spine 2005) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  71. 71. Pelvic Parameters Sacropelvic parameters • Compared changes between SVA and PT – Negative SVA (<0); PT = 10° – Neutral SVA (0-5 cm); PT = 16° – Positive SVA (> 5 cm); PT = 21° • SVA increases result in compensatory increase in PT • As PT increases, the SS decreases and PI remains constant. – PI = PT + SS • The degree of pelvic retroversion is essential in understanding the severity of sagittal plane imbalance and plays a key role in determining the amount of surgical correction. Increasing SVA  increase in PT  greater energy expenditure and greater disability Increasing PT to maintain neutral (A) No pelvic retroversion and high sagittal vertical axis (SVA). (B) Moderate pelvic retroversion and SVA. (C) High pelvic retroversion and no SVA. A B C bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  72. 72. Importance of Spinopelvic parameter's • A high PI/ PT are a predisposing factor for facet joint degeneration at the lower lumbar spine. • Increased PT values reflected pelvic retroversion and correlated with worsening Health-related quality of life (HRQOL) scores. • T1SPI was more accurately correlated with HRQOL scores than did sagittal vertical axis (SVA). Pourtaheri S et al. Pelvic retroversion: a compensatory mechanism for lumbar stenosis. J Neurosurg Spine 27:137–144, 2017 Lafage V, et al: Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:599–606, 2009 bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  73. 73. The SRS-Schwab adult spinal deformity classification : • this one correlated radiographic deformity with patient-reported outcomes, bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  74. 74. SRS-Schwab Classification • A classification system can reliably describe a deformity, and establish a basis for treatment. • The SRS-Schwab ASD classification includes a curve type descriptor, and a three sagittal spinopelvic modifiers: – PI-LL mismatch, SVA, and PT • The most important components are: – PI - LL within 10 degrees (normal) – SVA (quantifies global malalignment) – PT (measures the degree of pelvic retroversion) • Each classified as – Non- pathological (0) – Moderate deformity (+) – Marked deformity (+ +) (Schwab F, et al. Spine 2012) SRS-Schwab Classification for ASD bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  75. 75. SRS-Schwab Classification • These parameters are associated with HRQOL outcomes • They were established on the basis of patient-reported outcome data. • SRS –Schwab classification has – clinical relevance and applicable – surgical goals using the spinopelvic modifiers SRS-Schwab Classification for ASD (Schwab F, et al. Spine 2012) (Schwab F, et al. Spine 2010) (Terran JS, et al. Neurosurgery 2013) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  76. 76. sagittal balance • Positive sagittal balance • occurs when the C7 plumb line falls anterior to the posterior- superior corner of the S1 endplate. • Negative sagittal balance • occurs when the C7 plumb line falls posterior to the posterior- superior corner of the S1 endplate. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  77. 77. Negative sagittal balance • occurs when the C7 plumb line falls posterior • either fixed or flexible. • the imbalance can be either compensated or decompensated. “Compensated” either a) local (a few vertebra causing significant tilt), b) regional (many vertebra causing a slow forward bend), or c) a mix of the two bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  78. 78. Regional Sagittal malalignment kyphosis (T10-L1) • Regional deformity is characterized by sagittal malalignment within the • cervical, • thoracic or • lumbosacral regions of the spine. – Hypo kyphotic < 20°, – Hyperkyphotic > 60° – Hypo lordotic < 30° (Berthonnaud E, et al. J Spinal Disord Tech 2005) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  79. 79. Sagittal imbalance cascade: • Loss of lumbar lordosis. • Pelvic retroversion. • Hip extension. • Knee flexion. • Loss balance . • External support. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  80. 80. Compensation mechanisms for anterior segment imbalance. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  81. 81. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  82. 82. Causes of Sagittal imbalance: • Primary spine causes: - All causes of kyphosis (congenital, Ankylosing spondyliotis, Scheurman, Neuromuscular,…….). - Destructive lesions( Tumors, infections). - Traumatic lesions (fractures). - Degenerative lesions (multilevel disc disease, high grade spondylolisthesis). • Secondary spine causes: - Iatrogenic flat back. - Post laminectomy kyphosis. - Adjacent segment disease. • Extra spinal causes: - Hips and knees contractures. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  83. 83. Coronal imbalance: Coronal offset: • The distance between c7 plumb line and CSVL. • More than 4 cm has been correlated with poor function and increased disability. IT is defined the amount of coronal plane decompensation in centimeters. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  84. 84. Coronal plane deformity correction • Deviation • To left is negative, • To right is positive bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  85. 85. • Coronal deformity can be broken down into idiopathic (residual) ASD – the result of untreated adolescent idiopathic scoliosis in the adult • degenerative (de novo) ASD – defined as a progressive deformity in the adult caused by • degenerative changes • iatrogenic • paralytic • posttraumatic bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  86. 86. Pelvic Obliquity bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  87. 87. CLASSIFICATIONS of PO. I- Mayer (1936) : 1- Functional / non-structural PO : - Present only when pt. stands with knees straight & no lift under foot & disappear on sitting & on recumbency w legs parallel to midline of body - due to LLD. 2- Structural / fixed PO : -persists in all positions & cannot be passively corrected. -Etiology: a- infrapelvic (hips) b- pelvic c-suprapelvic ( spine) d- combined bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  88. 88. SUPRA-PELVIC FIXED PO.: - in cong. or neuromuscular scoliosis - not in idiopathic scoliosis ( curve not extend to pelvis ) INFRA-PELVIC FIXED PO. A- Congenital hip contracture: 1- cong. Abductor contracture 2- cong. Adduction contracture B- neuromuscular hip contractures : Abd, add or both. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  89. 89. pelvic obliquity • Pelvic obliquity and associated etiology should be considered in the coronal plane correction strategy. • Pelvic obliquity is quantified by measuring the angle formed between a horizontal reference line and a pelvic coronal reference line. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  90. 90. Treatment of patients with scoliosis, coronal misalignment and pelvic obliquity • All patients should be evaluated for a leg length discrepancy • Patients with a flexible curve due to pelvic obliquity as a result of a leg length discrepancy may respond well to the addition of a shoe lift only or surgical treatment of the leg length discrepancy. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  91. 91. Summary • Several radiographic parameters have been shown to correlate with patient quality of life and normative thresholds have been established. • Studies have shown that sagittal balance is the most important and reliable radiographic predictor of clinical health status in adult patients with spinal deformity. • Current radiographic goals include: – SVA within 5 cm – PI and LL mismatch less than 10° – PT less than 20° – T1SPi less than 1° • Restoration of these normal sagittal parameters has become a primary objective in ASD surgery. (Bhalla A, et al. Seminars in Spine Surgery, 2015), (Schwab FJ, et al. Spine 2013), (Lafage V, et al. Spine 2009), (Turner JD, et al. Eur Spine J 2015) bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  92. 92. TH-TH-TH-THAT’S ALL FOLKS! bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  93. 93. ‫ا‬.‫د‬.‫قرنة‬ ‫بهاء‬ Prof. Dr. Bahaa Kornah •. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT
  94. 94. bahaa Kornah- Al-Azhar UN.- Cairo-EGYPT

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