scoliosis and Physiotherapy Dec 2015 dnbid

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Scoliosis: Physiotherapy management:

Scoliosis: Physiotherapy management Dr. D. N. Bid Sarvajanik College of Physiotherapy Rampura , Surat -395003, India dnbid 1

Definition:

Definition Scoliosis is defined as a lateral curvature of the spine combined with a rotational component, due to various etiologies. : - Scoliosis Research Society (SRS). 2 dnbid

Classification of scoliosis :

Classification of scoliosis dnbid 3 Nonstructural scoliosis postural scoliosis compensatory scoliosis Transient structural scoliosis sciatic scoliosis hysterical scoliosis inflammatory scoliosis Structural scoliosis idiopathic (70 - 80 % of all cases) congenital neuromuscular poliomyelitis cerebral palsy syringomyelia muscular dystrophy amyotonia congenita Friedreich's ataxia trauma fractures irradiation surgery

Illustration of side-to-side spinal curvature that occurs with scoliosis:

Illustration of side-to-side spinal curvature that occurs with scoliosis dnbid 4

Patterns of scoliosis :

Patterns of scoliosis dnbid 5

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Causes:

Causes Congenital result of an abnormality of the development of the vertebrae Neuromuscular caused by cerebral palsy, spina bifida, muscular dystrophies, spinal cord injuries Poor posture Unequal leg length Idiopathic scoliosis cause unknown most common form (80%) 7 dnbid

Vertebral anomalies causing scoliosis :

Vertebral anomalies causing scoliosis dnbid 8

Secondary causes for scoliosis: Musculoskeletal disorders:

Secondary causes for scoliosis: Musculoskeletal disorders Leg length discrepancy Developmental hip dysplasia Osteogenesis imperfecta Klippel-Feil syndrome 9 dnbid

Natural history of scoliosis:

Natural history of scoliosis Of adolescents diagnosed with scoliosis, only 10% have curve progression requiring medical intervention Three main determinants of curve progression are: (1) Patient gender (2) Future growth potential (3) Curve magnitude at time of diagnosis 10 dnbid

Natural history of scoliosis:

Natural history of scoliosis Assessing future growth potential using Tanner staging: Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression 11 dnbid

Natural history of scoliosis:

Natural history of scoliosis Assessing growth potential using Risser grading: - Measures progress of bony fusion of iliac apophysis - Ranges from zero (no ossification) to 5 (complete bony fusion of the apophysis) - The lower the grade, the higher the potential for progression 12 dnbid

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Risk of Curve Progression Curve (degree) Growth potential ( Risser grade ) Risk * 10 to 19 Limited (2 to 4) Low 10 to 19 High (0 to 1) Moderate 20 to 29 Limited (2 to 4) Low/mod 20 to 29 High (0 to 1) High >29 Limited (2 to 4) High >29 High (0 to 1) Very high . *— Low risk = 5 to 15 percent; moderate risk = 15 to 40 percent; high risk = 40 to 70 percent; very high risk = 70 to 90 percent. 13 dnbid

Referral Guidelines & Treatment:

Referral Guidelines & Treatment Curve (degrees) Risser grade X-ray/refer Treatment 10 to 19 0 to 1 Every 6 months/no Observe 10 to 19 2 to 4 Every 6 months/no Observe 20 to 29 0 to 1 Every 6 months/yes Brace after 25 degrees 20 to 29 2 to 4 Every 6 months/yes Observe or brace * 29 to 40 0 to 1 Refer Brace 29 to 40 2 to 4 Refer Brace >40 0 to 4 Refer Surgery † 14 dnbid

Natural history of scoliosis:

Natural history of scoliosis Back pain not significantly higher in pts with scoliosis Curves in untreated adolescents with curves < 30 º at time of bony maturity are unlikely to progress Curves >50 º at maturity progress 1º per year Up to 19% of females with curves >40 º have significant psychological illness Life-threatening effects on pulmonary function do not occur until curve is >100 º (ie: Cor pulmonale) 15 dnbid

Idiopathic Scoliosis :

Idiopathic Scoliosis Idiopathic scoliosis is the most common type of spinal deformity. Its onset can be rather insidious, its progression relentless, and its end results deadly. Proper recognition and treatment of idiopathic scoliosis help to optimize patient outcomes. Once the disease is recognized, effective ways exist to treat it.

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Some Examples… 17 dnbid

Comparison of spinal alignment between unaffected teenager and a teenager with right idopathic scoliosis. :

Comparison of spinal alignment between unaffected teenager and a teenager with right idopathic scoliosis. Comparison of spinal alignment between unaffected teenager and a teenager with right idopathic scoliosis. dnbid 18

Coronal view of a scoliotic spine: the vertebrae and intervertebral discs are decreased in height on the concave side :

Coronal view of a scoliotic spine: the vertebrae and intervertebral discs are decreased in height on the concave side dnbid 19

Problem: :

Problem: It is, at times, grossly oversimplified as mere lateral deviation of the spine, when in reality, it is a complex 3-dimensional deformity (Asher, 1999). dnbid 20

Problem: :

Problem: In fact, some have used the term rotoscoliosis to help emphasize this very point. Two-dimensional imaging systems (plain radiographs) remain somewhat limiting, and scoliosis is commonly defined as greater than 10° of lateral deviation of the spine from its central axis. dnbid 21

Problem::

Problem: J.I.P. James is credited with classifying idiopathic scoliosis according to the age of the patient at the time of diagnosis (James, 1954). Using his classification system, children diagnosed when they are: younger than 3 years ► infantile idiopathic scoliosis . aged 3-10 years ► juvenile idiopathic scoliosis , and older than 10 years ► adolescent idiopathic scoliosis . These age distinctions, though seemingly arbitrary, have prognostic significance. dnbid 22

Frequency: :

Frequency: Scoliosis is almost always discussed in terms of its prevalence (i.e., the total number of existing cases within a defined population at risk). dnbid 23

Frequency::

Frequency: The prevalence of scoliosis was highest (1.2%) in patients aged 12-14 years (Stirling, 1996). Data such as these indicate that the focus of screening efforts should be on children in this age group. (12-14 years) dnbid 24

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EARLY EVALUATION OF SCOLIOSIS :

EARLY EVALUATION OF SCOLIOSIS SCHOOL SCREENING 26 dnbid

Etiology: :

Etiology: The precise etiology of idiopathic scoliosis remains unknown, but several intriguing research avenues exist. dnbid 27

Etiology::

Etiology: Disorganized skeletal growth, probably with its root cause at gene locus or group of loci, has been discussed as a possible etiologic explanation for idiopathic scoliosis. The Hueter-Volkmann principle states that compressive forces tend to stunt skeletal growth and distractive forces tend to accelerate skeletal growth. A possible, yet unproven, association with such a growth disturbance is the osteopenia that has been identified in patients with idiopathic scoliosis (Cheng, 1997). dnbid 28

Clinical History: :

Clinical History: The vast majority of patients initially present due to perceived deformity. This may be patient or family perception of asymmetry about the shoulders, waist, or rib cage. A primary care physician or school-screening nurse may perceive similar findings. Adams forward-bending test (in conjunction with the use of a scoliometer) has been found to be an effective screening tool. dnbid 29

Measures:

Measures A . With student standing (grid), observe for: a) high shoulder, b) curved spine, c) uneven shoulder blades, d) uneven hips or waist creases, and e) unequal distance from arm to side of body B. Adams forward bend test Scoliometer measurement (thoracic, thoracolumbar, lumbar) -Angle of trunk rotation (ATR) > 7 degree – referral) 30 dnbid

Bending position:

Bending position Bending position (Adam’s test). Student should stand erect with feet together, knees fully extended, and the palms of both hands touching each other as the student bends forward until the back is horizontal. Asymmetry of the thoracic or lumbar spine may be detected by using a scoliometer to measure the angle of trunk rotation (ATR) at the thoracic, thoracolumbar, and lumbar areas of the spine 31 dnbid

Adam’s forward bend test:

Adam’s forward bend test For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures. 32 dnbid

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Scoliometer:

Scoliometer The patient bends over, arms dangling and palms pressed together, until a curve can be observed in the upper back (thoracic area). The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve. The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured. An inclinometer (Scoliometer) measures distortions of the torso. 34 dnbid

Clinical History::

Clinical History: Traditionally, scoliosis has been described as a nonpainful condition, and aggressive workup has been recommended for patients in whom this rule is violated (Hensinger, 1995). dnbid 35

CLINICAL ASSESSMENT:

CLINICAL ASSESSMENT Physical Exam A. Trunk symmetry (Adams Forward Bend Test) B. Shoulder height C. Hip, pelvis, breast prominence D. Leg length E. Skin F. ROM G. Neurological exam – upper/lower limbs, abnormal reflexes 36 dnbid

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Physical examination should include a baseline assessment of posture and body contour . Shoulder unleveling and protruding scapulae are common. In the most common curve pattern (right thoracic), the right shoulder is consistently rotated forward and the medial border of the right scapula protrudes posteriorly. Assessment of lower (and often upper) extremity reflexes should be performed. Abdominal reflex patterns should also be assessed. The presence or absence of hamstring tightness should be investigated, and screening should be performed for ataxia and/or poor balance or proprioception (i.e., Romberg test). Measuring leg length will prove valuable, as a significant percentage of patients with scoliosis have several centimeters of limb-length discrepancy. dnbid 37

Physical Findings:

Physical Findings “tip-offs” to scoliosis: Uneven shoulders Prominent shoulder blade (s) Uneven waist Elevated hips Leaning to one side 38 dnbid

Measure spinal curvature using Cobb method::

Measure spinal curvature using Cobb method : Choose the most tilted verterbrae above & below apex of the curve. - Angle b/t intersecting lines drawn perpendicular to the top of the superior vertebrae and bottom of the inferior vertebrae is the Cobb angle. 39 dnbid

Cobb method for measurement of scoliosis :

Cobb method for measurement of scoliosis dnbid 40

measurement of rotational component of scoliosis :

measurement of rotational component of scoliosis dnbid 41

bending films may help to differentiate structural from nonstructural curves :

bending films may help to differentiate structural from nonstructural curves dnbid 42

determination of skeletal maturity :

determination of skeletal maturity dnbid 43

Determination of vertebral maturity :

Determination of vertebral maturity dnbid 44

SCOLIOSIS:

SCOLIOSIS PATIENT EVALUATION 45 dnbid

EVALUATION:

EVALUATION HISTORY PHYSICAL EXAM IMAGING LAB TEST DIAGNOSTIC PROCEDURES TIME LINE 46 dnbid

EARLY EVALUATION:

EARLY EVALUATION SCHOOL SCREENING OF SCOLIOSIS 47 dnbid

SCHOOL SCREENING:

SCHOOL SCREENING FORWARD BENDING TEST 48 dnbid

FBT:

FBT RIB HUMP 49 dnbid

TRUNK ASYMETRY:

TRUNK ASYMETRY NEED ORTHO EVALUATION 50 dnbid

ORTHOPAEDIC EVALUATION:

ORTHOPAEDIC EVALUATION HISTORY OF PAIN NEUROLOGICAL SYMPTOMS FAMILY HISTORY GROWTH SPURT MENARCHE 51 dnbid

ORTHOPAEDIC EVALUATION:

ORTHOPAEDIC EVALUATION REAR VIEW 52 dnbid

RIB HUMP:

RIB HUMP 53 dnbid

SPINE BALANCE:

SPINE BALANCE PLUMB LINE 54 dnbid

SPINE MOBILITY:

SPINE MOBILITY HAND SUSPENSION 55 dnbid

SPINE MOBILITY:

SPINE MOBILITY TRACTION XRAY 56 dnbid

ORTHOPAEDIC EVALUATION :

ORTHOPAEDIC EVALUATION FRONT VIEW 57 dnbid

LEG LENGTH :

LEG LENGTH INEQUALITY 58 dnbid

HAMSTRING TIGHTNESS:

HAMSTRING TIGHTNESS SLR 59 dnbid

HIP FLEXION CONTRACTURE:

HIP FLEXION CONTRACTURE THOMAS TEST 60 dnbid

NEUROLOGICAL EVALUATION:

NEUROLOGICAL EVALUATION 61 dnbid

NEUROLOGICAL EVALUATION:

NEUROLOGICAL EVALUATION 62 dnbid

COLLAGEN DISEASES:

COLLAGEN DISEASES LIGAMENT LAXITY 63 dnbid

RADIOLOGICAL EXAMINATION:

RADIOLOGICAL EXAMINATION 64 dnbid

SCOLIOSIS SEVERITY:

SCOLIOSIS SEVERITY 65 dnbid

SCOLIOSIS:

SCOLIOSIS SKELETAL MATURITY RISSER SIGN VERTEBRAL RING APOPHYSIS FUSION WRIST X-RAY 66 dnbid

RISSER SIGN:

RISSER SIGN 67 dnbid

RISSER SIGN:

RISSER SIGN ILIAC APOPHYSIS 0 – ABSENT 1- 25% 2- 50% 3- 75% 4- FULL EXCURSION 5- FUSED 68 dnbid

INDICATIONS::

INDICATIONS: The main treatment options for idiopathic scoliosis may be summarized as "the 3 O's": (1) observation, (2) orthosis, and (3) operative intervention. When to choose each of these treatments is a complicated matter. The risk of curve progression varies based on the idiopathic scoliosis group in which a patient belongs (i.e., infantile, juvenile, adolescent). dnbid 69

Infantile idiopathic scoliosis :

Infantile idiopathic scoliosis Although defined by a seemingly arbitrary age limit (<3 year at the time of diagnosis), infantile idiopathic scoliosis demonstrates marked differences that distinguish it from the other 2 categories of idiopathic scoliosis. Infantile idiopathic scoliosis is the only type of idiopathic scoliosis whose most common curve pattern is left thoracic. Infantile idiopathic scoliosis is the only type of scoliosis that is more common in boys. with any significant reputation for spontaneous resolution. dnbid 70

Infantile idiopathic scoliosis:

Infantile idiopathic scoliosis Nonoperative treatment of progressive infantile idiopathic scoliosis predominates and may involve the use of conventional thoracolumbosacral orthosis (TLSO)–type braces, Milwaukee-type braces, and even intermittent Risser casting. Some have questioned the value of bracing in infantile idiopathic scoliosis and have stated, "a curve that resolves in a brace would probably have resolved without treatment" (Herring, 2002). dnbid 71

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Modified Boston Model underarm brace used for most patients with idiopathic scoliosis dnbid 73

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Infantile idiopathic scoliosis:

Infantile idiopathic scoliosis If surgical treatment becomes necessary, anterior release and fusion followed by posterior spinal fusion with instrumentation is considered to be the functional treatment. Every effort should be made to delay such surgical intervention as long as possible to optimize spinal growth, but relentless curve progression should not be accepted or tolerated while awaiting some arbitrary chronologic age. dnbid 75

A treatment outline for infantile idiopathic scoliosis: :

A treatment outline for infantile idiopathic scoliosis: Curves less than 25° are preferentially observed and monitored with spinal radiographs at regular intervals. Curves exceeding these parameters are typically braced, with some consideration given to the value of intermittent Risser casting . Surgery is considered for curves not adequately controlled with nonoperative measures. dnbid 76

Juvenile idiopathic scoliosis :

Juvenile idiopathic scoliosis It is more common in females, and its most common curve pattern is a right thoracic curve (Robinson, 1996). dnbid 77

One potential treatment algorithm for juvenile idiopathic scoliosis is as follows: :

One potential treatment algorithm for juvenile idiopathic scoliosis is as follows: Observation for curves less than 25° with follow-up radiographs at regular intervals Bracing for curves that range from 25-40° and at least consideration of bracing (based on curve flexibility) for curves from 40-50° Bracing for smaller curves that demonstrate rapid progression to the 20-25° range Surgical intervention for inflexible curves that exceed 40° or virtually any curve that exceeds 50°. dnbid 78

Brace Treatment for Scoliosis:

Brace Treatment for Scoliosis Most common is Boston brace (aka Thoraco -lumbar-sacral orthosis ) Braces have 74% success rate at halting curve progression (while worn) Bracing does not correct scoliosis, but may prevent serious progression Usually worn until patient reaches Risser grade 4 or 5 79 dnbid

Brace Treatment for Scoliosis:

Brace Treatment for Scoliosis Of patients with 20 º - 29 º curves, only 40% of those wearing braces ultimately required surgery, compared to 68% of those not wearing back braces Length of wearing time correlates with outcome (At least 16 hrs per day leads to best chance of preventing curve progression) 80 dnbid

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Bracing and casting may be used outside the above-mentioned parameters in an effort to help control a large curve in a young child for whom the surgeon is attempting to optimize spinal growth. dnbid 83

Adolescent idiopathic scoliosis :

Adolescent idiopathic scoliosis Adolescent idiopathic scoliosis is the most common type. Progressive curvature may be predicted by a combination of physiologic and skeletal maturity factors and curve magnitude. Small curves in more mature patients have a substantially lower risk of progression (about 2%) than larger curves in more immature patients, in whom the risk is much higher (risk may approach or exceed 70%). dnbid 84

Adolescent idiopathic scoliosis:

Adolescent idiopathic scoliosis Treatment recommendations for adolescent idiopathic scoliosis are driven almost totally by curve magnitude (the only caveat being that brace treatment is thought to be effective only in patients who are still growing). It is thus somewhat ironic to note that stated recommendations urge observation for curves less than 30°, bracing of curves that reach the 30-40° range, and consideration of surgery for curves that exceed 40°. dnbid 85

Adolescent idiopathic scoliosis:

Adolescent idiopathic scoliosis This amounts to a 10° window between observation and major spinal surgery. It is even more ironic to note that 10° is a commonly discussed margin of error for measuring such scoliotic curves. Additional patient factors may also influence some orthopedic surgeons to brace patients with curves measuring less than 30° or in excess of 40°. For instance, a rapidly progressive curve in a 12-year-old child that suddenly goes from 16-26° may easily prompt bracing. dnbid 86

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TREATMENT:

TREATMENT Medical therapy: Nonoperative management consists of either mere observation or orthosis use. Observation is watchful waiting with appropriate intermittent radiographs to check for the presence or absence of curve progression. Orthosis use for scoliosis is discussed extensively below. No other treatments, including electrical muscle stimulation, physical therapy, spinal manipulation, and nutritional therapies, have been shown to be effective for managing the spinal deformity associated with idiopathic scoliosis. dnbid 89

TREATMENT:

TREATMENT The first widely used scoliosis brace with proven effectiveness was the Milwaukee brace . This brace was developed by Walter Blount and Albert Schmitt in 1946 (Moe, 1970). The brace was originally designed to be used as part of the surgical treatment of scoliosis and only later evolved into a stand-alone nonoperative treatment. dnbid 90

TREATMENT:

TREATMENT Milwaukee brace was effective in preventing significant curve progression in patients with 20-39° curves (Lonstein, 1994). These same authors recommended that adolescents with a curve of 25° and a Risser sign of 0 be braced immediately and not wait for evidence of curve progression (Lonstein, 1994). dnbid 91

TREATMENT:

TREATMENT Rowe and his colleagues performed a meta-analysis aimed at evaluating the efficacy of nonoperative treatments for idiopathic scoliosis (Rowe, 1997). They calculated the weighted mean proportion of success for 3 nonoperative treatments: observation, electrical stimulation, and bracing. They were able to successfully combine data on 1910 patients from 20 different studies for purposes of meta-analysis. Their main results are as follows (treatment, success rate): Treatment Success Rate Observation, 49% Electrical stimulation, 39% Bracing 8 hours per day, 60% Bracing 16 hours per day, 62% Bracing 23 hours per day, 93% dnbid 92

TREATMENT:

TREATMENT In part due to the aforementioned psychological and brace wear compliance issues, new approaches to bracing are being developed. One such approach is that developed by Dr. Christine Coillard and Dr. Charles Rivard of the St. Justine Hospital in Montreal, Canada. Their dynamic bracing approach is referred to as the SpineCor Brace or as the St. Justine Brace. It involves elastic straps that are anchored on a pelvic corset, and, based on curve morphology, these straps are tensioned to exert corrective forces. The brace is a radical departure from traditional plastic and metal orthoses . Early results with the St. Justine Brace are rather encouraging, with success rates comparable to those of traditional bracing. dnbid 93

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CLASSIFICATION CORRECTIVE MOVEMENT BRACE IN PLACE LEFT LUMBAR SpineCor Adult Treatment

SpineCor and Sagittal Balance:

SpineCor and Sagittal Balance Corrective movement for A nterior Sagittal Balance First have the patient stabilise their lordosis by the contraction of abdominal and gluteus muscles. Second translate the base of the thorax slightly forwards and upwards .

SpineCor Adult Brace:

SpineCor Adult Brace

Exercise methods :

Exercise methods dnbid 97

Physiotherapeutic Scoliosis Specific Exercises (PSSE):

Physiotherapeutic Scoliosis Specific Exercises (PSSE) Three-dimensional scoliosis treatment Curve pattern specific exercises B ased on 3D auto-correction, training in ADL, stabilizing the correct posture and patient education The first step to treat idiopathic scoliosis to prevent progression The PSSE programs are designed only by Certified Physiotherapists Schroth method is the most established and evidence-based of the PSSE

Aims of PSSE:

Aims of PSSE Prevent progression of the curvature Reduce the deformity Improve Quality of Life Aesthetics improvement Pain reduction Improvement of Vital Capacity and chest expansion Training for ADL activities

Schroth Best Practice :

Schroth Best Practice Highly corrective exercises, looking for overcorrection dependent on the curvature type

Schroth Best Practice :

Schroth Best Practice Activities of Daily Living (ADL) training in standing and sitting positions according to curve pattern

Schroth Best Practice:

Schroth Best Practice Truly 3-dimensional exercises, sagittal plane correction during Schroth exercises

Schroth Best Practice:

Schroth Best Practice Truly 3-dimensional exercises, sagittal plane correction during Schroth exercises

Schroth method:

Schroth method Rotational Angular Breathing (RAB) creates forces to derotate the vertebrae and the rib cage. Expand the collapsed areas during inhalation, stabilize the correction/expansion during exhalation

Schroth method :

Schroth method Schroth method for adult scoliosis. Main aims are pain reduction, aesthetics and quality of life improvement

TREATMENT:

TREATMENT Surgical therapy: Even in the setting of adequate correction and solid fusion, up to 38% of patients still have occasional back pain ( Lenke , 1998). The primary goal of scoliosis surgery is to achieve a solid bony fusion. dnbid 106

TREATMENT:

TREATMENT Modern instrumentation systems have been shown to allow for adequate curve correction but with little or no ability to diminish associated rib humps ( Lenke , 1992). Despite claims of certain instrumentation systems to derotate the spine, little actual derotation has been documented. Derotation of the instrumented curve also has been shown to possibly occur at the expense of creation of new rotation in uninstrumented portions of the spine ( Rajasekaran , 1994). dnbid 107

Surgical Options:

Surgical Options Posterior correction and instrumentation Anterior correction and instrumentation Anterior release / fusion, plus posterior instrumentation Posterior release/fusion, plus anterior instrumentation Combined anterior and posterior instrumentation and fusion 108 dnbid

Postoperative details: :

Postoperative details: Postoperative patient management involves close monitoring, which often occurs initially in an intensive care unit setting. Patients have monitoring devices, such as arterial lines, and closed suction devices, such as chest tubes, that also require special nursing attention. The use of certain special spine-specific hospital beds, such as the Stryker frame , may also aid in patient care and comfort (change from supine to prone position) during the initial postoperative period. dnbid 109

Postoperative details: :

Postoperative details: The use of postoperative bracing varies from surgeon to surgeon. The roots of scoliosis surgery involved immobilization in a body cast. Following the development of initial instrumentation systems (eg, Harrington instrumentation), external immobilization was still used routinely. With the advent of large-rod multiple-hook constructs, such as the Cotrel-Dubousset system and its direct decendents, bracing has been de-emphasized a bit. dnbid 110

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Today, it is almost as likely that a patient will not receive a postoperative brace. In certain specific circumstances, postoperative bracing is still almost always used, such as anterior thoracic or thoracolumbar instrumentation procedures or surprisingly weak bone stock. dnbid 111

Postoperative details: :

Postoperative details: When a brace is used, it is typically to be worn full-time for at least 6 weeks, followed by a period in which the brace may be off for bathing with subsequent progressive weaning. As a rule of thumb, patients may also miss up to 6 weeks of school (if their procedure is done at such time of the year), and up to 6 months may be required before they resume most of their normal activities. Vigorous sports may be restricted for at least a year, in some instances permanently (based on risk versus benefit discussions between patients, families, and their surgeons). dnbid 112

Posterior segmental instrumentation for three-dimensional correction of spinal alignment. :

Posterior segmental instrumentation for three-dimensional correction of spinal alignment. dnbid 113

Patient with thoracic scoliosis, convex to the right, bridged by a Harrington rod and bone graft along the concave side of the spine :

Patient with thoracic scoliosis, convex to the right, bridged by a Harrington rod and bone graft along the concave side of the spine dnbid 114

OUTCOME AND PROGNOSIS:

OUTCOME AND PROGNOSIS Clinical outcomes following treatment of idiopathic scoliosis are strongly linked to curve magnitude. dnbid 115

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www.slideshare.com THANK YOU Thank you for your attention dnbid 116

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