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Local revision copy · not clinical advice

Spine Paed

Topic 20 · slides 569–583 · 15 slides · 104 questions
15 slides
▸ Slide 569 · SpineSpine Paed · 3 questions expand
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slide 569
Question list
Q1-Q33 questions — tap to reveal all answerslist
  1. How would you assess a child with a suspected spinal deformity?
  2. Which investigations are used for paediatric spine conditions?
  3. What are the surgical indications in paediatric spinal deformity?
Answers · Q & A
Q1.How would you assess a child with a suspected spinal deformity?
  • Not covered in the speaker notes
Q2.Which investigations are used for paediatric spine conditions?
  • Not covered in the speaker notes
Q3.What are the surgical indications in paediatric spinal deformity?
  • Not covered in the speaker notes
▸ Slide 570 · TorticollisSpine Paed · 14 questions expand
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slide 570
Question list
Q1-Q1414 questions — tap to reveal all answerslist
  1. What are the causes of torticollis?
  2. Describe the Fielding CT classification of atlantoaxial rotatory instability.
  3. How does management of AARI depend on timing?
  4. What are the indications and types of surgery for congenital muscular torticollis?
  5. What are the dangers of bipolar release?
  6. What is the evidence for conservative management of CMT (Cheng 2001)?
  7. What are the clinical features of the torticollis patient shown?
  8. What history is important in torticollis?
  9. What examination findings should be sought in torticollis?
  10. What investigations are used in torticollis?
  11. What is Grisel's syndrome?
  12. What is the pathophysiology of congenital muscular torticollis?
  13. Describe the bipolar release technique.
  14. Why are children more prone to atlantoaxial rotatory instability?
Answers · Q & A
Q1.What are the causes of torticollis?
  • Congenital (usually painless): CMT, Klippel-Feil
  • Acquired osseous (usually painful): AARI (trauma, tumour, infection, odontoid hypoplasia in Down's/achondroplasia, JRA/RA)
  • Non-osseous: ENT, eye (squint), CNS (Arnold Chiari), postural (usually painless), neck burns
Q2.Describe the Fielding CT classification of atlantoaxial rotatory instability.
  • 1: Unilateral subluxation with intact transverse ligament (dens is the pivot)
  • 2: Unilateral anterior subluxation 3-5mm (opposite facet acts as pivot)
  • 3: Bilateral anterior subluxation >5mm
  • 4: Posterior subluxation
Q3.How does management of AARI depend on timing?
  • <1 week: soft neck collar, analgesics
  • 1-4 weeks: Halter traction (2-3kg), 1hr off/3hr on cycle, until reduced, then SOMI 4wk
  • >4 weeks: halo traction 4 weeks, high chance of failure then OT fusion C1-2
  • Other OT indications: irreducible >3 months, neurological deficit, recurrent
Q4.What are the indications and types of surgery for congenital muscular torticollis?
  • Presentation >1 year
  • >15 degree head tilt/lag with tumour
  • Failed conservative management x6 months
  • Unipolar release: sternal head <3yo, sternal + clavicular head 3-6yo
  • Bipolar release >6-10 years (alternative Z plasty)
  • Dangers: greater auricular nerve (surface), CNXI (deep), facial nerve (anterior)
Q5.What are the dangers of bipolar release?
  • Surface - greater auricular nerve
  • Underneath - CNXI (CN XI)
  • Anterior - facial nerve
Q6.What is the evidence for conservative management of CMT (Cheng 2001)?
  • 800 patients with onset <1 year
  • 95% good response to physiotherapy (flexion, rotation, tilting), mean follow-up 4.5 years
  • Poor prognostic factors: 15deg rotation deficit, SCM tumour, late presentation (present >1yo) (also stated as >15 degree rotation deficit, SCM tumour, late presentation >1 year)
Q7.What are the clinical features of the torticollis patient shown?
  • Head tilting to the right and rotating to the left
  • No plagiocephaly or facial asymmetry
  • No neck scar, no obvious strabismus
Q8.What history is important in torticollis?
  • Perinatal history: oligohydramnios, breech, first born; known congenital conditions (e.g. Klippel-Feil)
  • Pain, onset of symptoms, progression, trauma, previous treatment or H&N problems
  • Hearing or optical impairment, recent URI symptoms, functional impairment
Q9.What examination findings should be sought in torticollis?
  • Plagiocephaly, low hairline, scapula (KF syndrome); facial dysmorphism/asymmetry
  • SCM spasm, tumour, cervical LN
  • Rotation and tilt lag 15 degrees; squint, hearing; neuro exam
  • If newborn, look for other packaging disorders
Q10.What investigations are used in torticollis?
  • Bloods: CBC, inflammatory markers
  • Xray: lateral mass asymmetry on open mouth view, lateral for ADI, trapezoidal anterior C1 shadow, oval posterior arch sign; exclude fracture or congenital abnormalities
  • Dynamic CT is gold standard for AARI (book if failed initial conservative management), 3 sets to look for fixed relationship between C1 and C2
  • +/- contrast to rule out retropharyngeal abscess if raised inflammatory markers; +/- MRI to exclude infection or tumour
Q11.What is Grisel's syndrome?
  • Drainage of inflammatory mediators through the pharyngovertebral vein to the periodontoid plexus
  • Leads to ligamentous laxity
Q12.What is the pathophysiology of congenital muscular torticollis?
  • Local compartment syndrome of the SCM
  • Remember to look for other packaging disorders
Q13.Describe the bipolar release technique.
  • 2cm incision below the mastoid, strip attachment from bone
  • 2cm incision above the sterno-clavicular junction, incise platysma, cut both heads of SCM with the deep fascia
  • Postop: intensive stretching for 3 months; >2yo add adjustable torticollis brace for 3 months
Q14.Why are children more prone to atlantoaxial rotatory instability?
  • Capsular laxity
  • Facet more transverse
▸ Slide 571 · Acute curve at TLJ convex to right sideSpine Paed · 8 questions 1 check expand
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slide 571
Question list
Q1-Q88 questions — tap to reveal all answerslist
  1. What is congenital scoliosis and how is it classified?
  2. What associated anomalies should be screened for in congenital scoliosis?
  3. What is the natural history of congenital scoliosis?
  4. What are the surgical options for congenital scoliosis?
  5. Which types of congenital scoliosis may be observed without surgery?
  6. What are the clinical and radiological clues in this case?
  7. What history and examination are needed in suspected congenital scoliosis?
  8. What is the aim of management in congenital scoliosis?
Answers · Q & A
Q1.What is congenital scoliosis and how is it classified?
  • Failure to form normal vertebrae at gestation week 4-6
  • Failure of formation / segmentation / mixed (MacEwen classification)
  • Failure of formation divided by segmentation (segmented, semisegmented, nonsegmented) and extent (partial vs complete)
  • Most are sporadic
Q2.What associated anomalies should be screened for in congenital scoliosis?
  • Extraspinal: VACTERL, Klippel-Feil, NF
  • Intraspinal: Chiari malformation, tethered cord, syrinx - MRI
  • Internal organs: renal USG and echo
Q3.What is the natural history of congenital scoliosis?
  • McMaster: 485 patients, 75% need surgical treatment
  • Prognosis depends on type of anomaly and anatomical site
  • Progression by type: mixed > unilateral bar > fully segmented > partially segmented > incarcerated > nonsegmented
  • Position: TLJ worse; also younger age
Q4.What are the surgical options for congenital scoliosis?
  • Early in situ fusion for minimal deformity (young: A+P fusion; older: P fusion)
  • Hemivertebrectomy for marked truncal imbalance (<5yo, flexible curves <40)
  • Convex hemiepiphysiodesis for unilateral failure of formation (<5yo, progressive curves <40-50)
  • Spinal column shortening resection for rigid, severe late deformities with decompensation
  • Growing rods maximise spinal growth but are controversial
Q5.Which types of congenital scoliosis may be observed without surgery?
  • Incarcerated hemivertebrae
  • Nonsegmented hemivertebrae
  • Some partially segmented hemivertebrae
  • Selected because of absence of progression
Q6.What are the clinical and radiological clues in this case?
  • Acute curve at the TLJ convex to the right
  • One pedicle less on the left, seems unsegmented
  • Suspect congenital scoliosis with hemivertebra
Q7.What history and examination are needed in suspected congenital scoliosis?
  • Hx: birth history, walking age and motor development, associated problems (Klippel-Feil, NF, VACTERL)
  • PE: maturity (Tanner-Whitehouse), shoulder balance, rib or loin hump, truncal shift or listing
  • Neurology, gait, skin stigmata
Q8.What is the aim of management in congenital scoliosis?
  • Arrest progression
  • Achieve a balanced spine while preserving as much spinal growth as possible
Fact check

McMaster's natural history paper studied 485 patients, 75% needing surgery — Incorrect patient number — McMaster & Ohtsuka (JBJS 1982) studied 251 patients; 485 does not match the cited source — source

▸ Slide 572 · XR showing scoliosis, with major right thoracic curve. Apex as T8/9. Cobb angle Spine Paed · 13 questions expand
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slide 572
Question list
Q1-Q1313 questions — tap to reveal all answerslist
  1. What are the indications for MRI in scoliosis?
  2. How do you assess maturity and risk of progression?
  3. What is the brace treatment and its evidence?
  4. What are the indications and aims of surgery in AIS?
  5. Compare anterior and posterior fusion in AIS.
  6. Why operate in AIS (natural history)?
  7. Describe the XR findings in this AIS case.
  8. What history and maturity assessment is needed in AIS?
  9. What are the components of the general and standing examination in AIS?
  10. Which classifications are used for AIS curves?
  11. How is a brace weaned in AIS?
  12. What are the key elements of scoliosis surgery?
  13. Describe the Hong Kong scoliosis screening programme.
Answers · Q & A
Q1.What are the indications for MRI in scoliosis?
  • Left-sided thoracic curve
  • Short angular curve, angled kyphosis
  • Neurology, pain
  • <10yr + >20 deg (<10 years + >20 degrees)
  • Rapid curve progression
Q2.How do you assess maturity and risk of progression?
  • Age 9-13 with >2 years before menarche
  • growth rate >2cm/yr (>2cm/year)
  • Risser 0-1, hand XR capped stage (TW III), open triradiate cartilage
  • Risser stages: I prepubertal, II growth spurt, III decreasing growth rate, IV variable
  • Limitations: peak height velocity and 2/3 of growth spurt occur before Risser I; curve may not stop at Risser IV
Q3.What is the brace treatment and its evidence?
  • The aim of the brace is to slow down curve progression; effect is dosage related (>20 hr/day -> 93% success)
  • Keep bracing till skeletal maturity
  • Weinstein BRAIST trial (NEJM 2013): 72% success vs 48% observation
  • Complications: GI regurgitation, skin irritation/dermatitis/folliculitis, pressure, low self-esteem
Q4.What are the indications and aims of surgery in AIS?
  • Curves >45 degrees in a growing patient or >50 degrees when growth has stopped
  • Aim: correct deformity, square fusion block with <2cm listing and <20 degree tilt
  • Include all structure curves (i.e. all structural curves) while saving fusion segments
  • Stable fusion and prevent complications
Q5.Compare anterior and posterior fusion in AIS.
  • Anterior: short segment, increase correction power by discectomy, for hypokyphosis; disadvantage difficult exposure
  • Posterior: easy exposure; disadvantage long segment, difficult full correction
  • Combined indications: stiff curve (>50 residual on FB XR), severe curve (>70), immature (female <10, male <13) to prevent crankshaft
Q6.Why operate in AIS (natural history)?
  • Progression >50 degrees -> more likely SOB; >70 deg --> decreased lung function; >100 deg increase risk of death
  • Increased mortality and cardiopulmonary compromise
  • Truncal imbalance and back pain
Q7.Describe the XR findings in this AIS case.
  • Major right thoracic curve, apex T8/9, Cobb angle 40 degrees
  • Shoulders and pelvis level; truncal shift and truncal listing
  • No vertebral anomalies such as hemivertebrae or unsegmented bar, ribs normal; Risser sign 3; Triradiate cartilage status
Q8.What history and maturity assessment is needed in AIS?
  • Birth history, developmental history and family history of scoliosis
  • Current symptoms: age of onset and progression, pain or neurological symptoms, visceral problems
  • Assess maturity: menarche, growth spurt
Q9.What are the components of the general and standing examination in AIS?
  • General: body height, arm span, sitting height; cutaneous lesions; ligamentous laxity/marfanoid features; spinal dysraphism
  • Standing coronal: shoulder/pelvis symmetry, rib or loin hump, decompensation (truncal shift and list)
  • Sagittal: hypokyphosis, kyphoscoliosis; bend forward for flexibility; gait (scissoring gait)
  • Sit: postural scoliosis; supine: neuro exam + superficial abdominal reflexes; finish by checking secondary sexual characteristics
Q10.Which classifications are used for AIS curves?
  • Lenke classification, King classification, Peking Union Medical College (PUMC), Labelle 3D
  • This case is a major thoracic curve
Q11.How is a brace weaned in AIS?
  • At skeletal maturity: no growth in 18 months, Risser 4, menarche >2 years, DR and DU physis closed
  • Done in a gradual manner - no hard science; e.g. spread over 4 months with stepwise decrease in hours/day
Q12.What are the key elements of scoliosis surgery?
  • Posterior approach; subperiosteal dissection till transverse processes
  • Identify upper and lower instrumented vertebrae (ASF: end to end; PSF: proximal end; distal Lenke I-II: most distal VB touched by CVSL, III-VI: distal end VB)
  • Pedicle screw insertion; reduction techniques: Harrington forces, cantilever bending, translation, rod rotation, direct vertebral rotation
  • Decortication with bone graft to interlaminar space and into facets
Q13.Describe the Hong Kong scoliosis screening programme.
  • 3 tier system starting in P5
  • FBT + ATR >=15 -> refer to scoli centre
  • 5-14: Moire topography -> >=2 lines -> XR -> >20 degrees -> refer specialist hospital
  • <5: re-refer to screening programme
▸ Slide 573 · AISSpine Paed · 6 questions expand
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Question list
Q1-Q66 questions — tap to reveal all answerslist
  1. What does the Nash-Moe technique assess?
  2. How do you describe the X-ray in AIS?
  3. What is the aim of clinical assessment in AIS?
  4. What are the key clinical findings on examination in AIS?
  5. What imaging is required in AIS?
  6. What is the management principle in AIS and how is a progressing curve predicted?
Answers · Q & A
Q1.What does the Nash-Moe technique assess?
  • Vertebral rotation
  • A radiographic measure of rotation in scoliosis (AIS)
Q2.How do you describe the X-ray in AIS?
  • Number, side and level of curve
  • Rotation of vertebrae (Nash-Moe)
  • Cobb angle
  • Feature of dysplastic curve
Q3.What is the aim of clinical assessment in AIS?
  • Aim: determine structural, severity, correctable
  • Look for neurology, cause, maturity
Q4.What are the key clinical findings on examination in AIS?
  • General: abnormal facial feature, skin change, laxity
  • Look: convexity of spine, asymmetrical waist line, list/shift/plumb line, shoulder, pelvis level
  • Sagittal kyphosis assessment
  • Move: AFB test for hump + scoliometer / side bending
  • Sit: sitting shoulder level, correctability
  • Supine: LLD, pelvic obliquity, neurology, abdominal reflex
Q5.What imaging is required in AIS?
  • Xray of whole spine AP + lateral
  • Fulcrum bending Xray
  • Pelvis and hand X-ray for skeletal maturity
  • MRI in any abnormal curve
Q6.What is the management principle in AIS and how is a progressing curve predicted?
  • Rule out other causes: extra-spinal (LLD, pelvic obliquity) and intra-spinal (congenital, neuromuscular, syndromes - NF, Ehlers-Danlos, Marfan)
  • Stop progression in slow progress; stop progression + correct deformity in fast progress and severe curve
  • Predict progressing curve - patient: sex (F>M), skeletal maturity
  • Predict progressing curve - curve: severity, thoracic > lumbar, double curve, previous progression
▸ Slide 574 · AISSpine Paed · 4 questions expand
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Question list
Q1-Q44 questions — tap to reveal all answerslist
  1. What are the treatment options for AIS?
  2. What are the indications, principles and complications of bracing in AIS?
  3. What are the indications and principle of operative treatment in AIS?
  4. How is the fusion level chosen and what instrumentation is used in AIS?
Answers · Q & A
Q1.What are the treatment options for AIS?
  • Treatment option: observe
  • Brace above T7 (Milwaukee/Boston)
  • Operation
Q2.What are the indications, principles and complications of bracing in AIS?
  • Indication: >20 degrees in a skeletally immature patient
  • 3 point fixation
  • Continue till skeletal maturity with gradual wean off
  • Assessment: compliance, complication, progression of curve
  • Complications: sore, esophagitis, stiffness
Q3.What are the indications and principle of operative treatment in AIS?
  • Indication: >40 degrees if immature, >50 degrees if mature
  • Principle: stop progression + correct deformity
  • Include all structural curves, achieving a solid fusion block with minimal tilting and shift
Q4.How is the fusion level chosen and what instrumentation is used in AIS?
  • Level depends on instrumentation, usually referenced to end vertebrae (mildly tilted) or stable vertebrae (vertebrae bisected by the mid-sacral line)
  • Classical: Luque rod, Harrington rod (cannot control rotation), pedicle screws with rod
▸ Slide 575 · AISSpine Paed · 3 questions expand
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Question list
Q1-Q33 questions — tap to reveal all answerslist
  1. What is the progression risk for a Risser 2 patient with a curve of 20-29 degrees?
  2. How do treatment and progression risk vary with Risser grade and curve angle?
  3. At what curve magnitude does treatment start and when is growth most rapid?
Answers · Q & A
Q1.What is the progression risk for a Risser 2 patient with a curve of 20-29 degrees?
  • Risser 2
  • Curve 20-29 degrees
  • Progression risk 22%
Q2.How do treatment and progression risk vary with Risser grade and curve angle?
  • Risser 0-1 (pre-menarche): 10-19 physio (22% curve progression); 20-29 brace (68%); 30-39 brace; 40-49 surgery; >50 surgery
  • Risser 2-3 (<1 year after menarche): 10-19 physio (2%); 20-29 physio (22%); 30-39 brace; 40-49 ?surgery (for curve >45); >50 surgery
  • Risser 4-5: physio for 10-19, 20-29, 30-39 and 40-49; >50 surgery
Q3.At what curve magnitude does treatment start and when is growth most rapid?
  • Start treatment at 20-30 degrees
  • Time of most rapid growth is at Risser 0
▸ Slide 576 · ClassificationSpine Paed · 5 questions expand
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Question list
Q1-Q55 questions — tap to reveal all answerslist
  1. What does the PUMC classification include?
  2. What does the King classification describe?
  3. What does the Lenke classification describe?
  4. How are curve sites defined in the Lenke classification?
  5. What defines a structural curve?
Answers · Q & A
Q1.What does the PUMC classification include?
  • Peking Union Medical College classification of AIS
  • Includes axial rotation
Q2.What does the King classification describe?
  • King's - site of curve
  • Double, lumbar major
  • Double, thoracic major
  • Single thoracic
  • L thoracic (include L4)
  • Double thoracic
  • --> Guide usage of Harrington rod
Q3.What does the Lenke classification describe?
  • Number and site of structural curve (6)
  • Modifiers: central sacral vertical line to lumbar apex, kyphosis
  • Curve site: proximal thoracic, main thoracic, TLJ/lumbar
  • Types: main thoracic, double thoracic, double major, triple major, thoracolumbar, thoracolumbar/lumbar + main thoracic
Q4.How are curve sites defined in the Lenke classification?
  • T: T2-T11/12 disc
  • TLJ (thoracolumbar junction): T12 - L1
  • L: L1/2 disc - L4
Q5.What defines a structural curve?
  • Side bending Cobb's angle ≥25 degrees
  • Kyphosis ≥20 degrees
▸ Slide 577 · NM scoliosisSpine Paed · 4 questions expand
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Question list
Q1-Q44 questions — tap to reveal all answerslist
  1. What is the Lonstein and Akbarnia classification of neuromuscular scoliosis?
  2. What is the deformity pattern in neuromuscular scoliosis and why?
  3. How is juvenile scoliosis classified and which group has a poorer prognosis?
  4. What is the management of neuromuscular/juvenile scoliosis?
Answers · Q & A
Q1.What is the Lonstein and Akbarnia classification of neuromuscular scoliosis?
  • 1: level pelvis (S curve)
  • 2: pelvic obliquity (C curve)
Q2.What is the deformity pattern in neuromuscular scoliosis and why?
  • C curve
  • Frontal: primary from erector spinae imbalance; secondary compensatory for hip adductor contracture
  • Sagittal: most compensation for hip -> hyperlordosis
  • TL/L more involved as more mobile; more listing; long fusion
Q3.How is juvenile scoliosis classified and which group has a poorer prognosis?
  • Early onset <5 years vs late onset >5 years
  • <5 years has poorer prognosis due to thoracic insufficiency syndrome
Q4.What is the management of neuromuscular/juvenile scoliosis?
  • <20 degrees: observation
  • Cobb 20-50: brace
  • Cobb >50: growth modulation with growing rods or tether if growth potential remains
  • If surgery/fusion, may need to consider adding anterior instrumentation
▸ Slide 578 · Other scoliosisSpine Paed · 8 questions expand
slide 578
Question list
Q1-Q88 questions — tap to reveal all answerslist
  1. What is juvenile scoliosis and how is it subdivided?
  2. How is juvenile scoliosis managed according to Cobb angle?
  3. What is the natural history of infantile scoliosis and why is MRI needed?
  4. What is the rib-vertebral angle difference (Mehta angle)?
  5. What are the three predictors for infantile curve growth?
  6. How is infantile scoliosis treated according to Cobb angle and RVAD?
  7. What types of scoliosis are covered under 'other scoliosis'?
  8. What is the rib phase in infantile scoliosis and what does overlap mean?
Answers · Q & A
Q1.What is juvenile scoliosis and how is it subdivided?
  • Early onset (<5 years) vs late onset (>5 years)
  • <5 years: poorer prognosis due to Thoracic Insufficiency Syndrome
  • Juvenile scoliosis requires MRI
Q2.How is juvenile scoliosis managed according to Cobb angle?
  • Cobb <20 degrees: observation
  • Cobb 20-50 degrees: brace
  • Cobb >50 degrees: growth modulation with growing rods or tether if growth potential remains
  • If fusion is needed, consider adding anterior instrumentation
Q3.What is the natural history of infantile scoliosis and why is MRI needed?
  • Most resolve spontaneously
  • Most common curve: left thoracic (75%)
  • MRI needed: 20% present with neuroaxial abnormalities and to rule out tethered cord
Q4.What is the rib-vertebral angle difference (Mehta angle)?
  • Angle between a perpendicular line from the apical vertebra endplate and the rib, comparing both sides
  • Rib phase: overlap of rib and vertebral body (phase 2) = non-resolving curve
Q5.What are the three predictors for infantile curve growth?
  • Cobb >20 degrees
  • Rib-vertebral angle difference (Mehta angle) >20 degrees
  • Rib-vertebral overlap (rib phase 2)
Q6.How is infantile scoliosis treated according to Cobb angle and RVAD?
  • Cobb <25, RVAD <20: observation
  • Cobb <35, RVAD >20: Mehta serial casting and bracing
  • Cobb >50: surgery with VEPTR or growing rods
Q7.What types of scoliosis are covered under 'other scoliosis'?
  • Juvenile scoliosis
  • Infantile scoliosis
  • Congenital scoliosis
Q8.What is the rib phase in infantile scoliosis and what does overlap mean?
  • Rib phase is the overlap of the rib and vertebral body
  • Overlap = rib phase 2 = non-resolving curve
▸ Slide 579 · VEPTR (Vertical Expandable Prosthetic Titanium Rib)Spine Paed · 3 questions expand
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slide 579
Question list
Q1-Q33 questions — tap to reveal all answerslist
  1. What does VEPTR stand for?
  2. What is the role of VEPTR in early-onset scoliosis?
  3. When is VEPTR used in the lecture?
Answers · Q & A
Q1.What does VEPTR stand for?
  • Vertical Expandable Prosthetic Titanium Rib
  • Not covered in the speaker notes beyond the title
Q2.What is the role of VEPTR in early-onset scoliosis?
  • Not covered in the speaker notes
  • Review the slide image and lecture recording
Q3.When is VEPTR used in the lecture?
  • Mentioned for infantile scoliosis with Cobb >50 degrees, together with growing rods
  • This slide itself has no speaker notes - the title is the only source
▸ Slide 580 · Physical exam:Spine Paed · 10 questions expand
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Q1-Q1010 questions — tap to reveal all answerslist
  1. What is spinal bifida and what are its risk factors?
  2. List the forms of spinal bifida.
  3. What causes neurological deterioration in spinal bifida?
  4. How is the functional level assessed in spinal bifida?
  5. What are the principles of treatment in spinal bifida?
  6. How are the hip, knee and ankle managed surgically in spinal bifida?
  7. What are the physical examination findings in spina bifida?
  8. How does spina bifida present?
  9. What causes scoliosis in spina bifida?
  10. At which functional level is hip dislocation the highest risk in spina bifida and why?
Answers · Q & A
Q1.What is spinal bifida and what are its risk factors?
  • Fetal neural plate fails to completely close
  • Risk factors: folate deficiency, maternal diabetes, chromosomal abnormality
Q2.List the forms of spinal bifida.
  • Spina bifida occulta: cord and meninges confined
  • Meningocele: protruded sac, no neural elements
  • Myelomeningocele: protruded sac with neural elements
  • Rachischisis: neural elements exposed
Q3.What causes neurological deterioration in spinal bifida?
  • Tethered cord
  • Hydrocephalus
  • Syringomyelia
Q4.How is the functional level assessed in spinal bifida?
  • Walk? yes at least L3
  • Ankle equinus? no at least L4
  • Hip abduction? yes at least L5
  • If not walking: check hip control - no at L1 or above, yes with flexion at L2
Q5.What are the principles of treatment in spinal bifida?
  • Treatment depends on the form and level
  • Aim: maximise function consistent with the level involved and prevent deterioration
  • Multidisciplinary approach with patient and family counselling
  • Community-based treatment, minimise hospital admission
  • Orthosis and physiotherapy for stretching to prevent contracture and maintain muscle power
  • Surgery to balance muscle pull, prevent or correct deformity
Q6.How are the hip, knee and ankle managed surgically in spinal bifida?
  • Hip: highest dislocation rate at L3/L4 last functional level due to adductor-abductor imbalance
  • Hip surgery is controversial and only applicable with functional quadriceps
  • Knee: flexion contracture release if severe and affecting walking
  • Ankle: can be equinovarus, cavovarus or calcaneovalgus
Q7.What are the physical examination findings in spina bifida?
  • Very short and slim lower limbs, upper limbs normal, AFO
  • Scar: longitudinal, mostly at the back
Q8.How does spina bifida present?
  • Deformity due to imbalanced muscle pull (hip dislocation, ankle deformity)
  • Contracture
  • Scoliosis (congenital / muscle imbalance / secondary to unilateral hip dislocation with LLD)
  • Functional deficit (walking difficulty)
  • Neurogenic bladder
  • Foot deformities
Q9.What causes scoliosis in spina bifida?
  • Congenital curve
  • Muscle imbalance
  • Secondary to unilateral hip dislocation with LLD
Q10.At which functional level is hip dislocation the highest risk in spina bifida and why?
  • L3 (with L4, the last functional levels) - intact adductor but weak abductor
  • L3 patients are household walkers
▸ Slide 581 · L4 calcaneusSpine Paed · 6 questions expand
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Q1-Q66 questions — tap to reveal all answerslist
  1. Using the functional-level table, summarise the hip, knee, ankle and functional findings at each level.
  2. At which levels is the ankle in equinus and at which level can it dorsiflex?
  3. Which levels can extend the knee and which level can walk?
  4. What does the slide title 'L4 calcaneus' refer to?
  5. Which functional levels have hip flexion with adduction and which can abduct?
  6. Which levels are Trendelenburg positive and which level has claw toes?
Answers · Q & A
Q1.Using the functional-level table, summarise the hip, knee, ankle and functional findings at each level.
  • L1: hip ER + F (budda), knee flex, ankle equinus, flaccid
  • L2: hip flex + add, knee flex, ankle equinus, +ve hip flexion
  • L3: hip flex + add, knee can extend, ankle equinus, can walk (indoor), hip trdelenberg
  • L4: hip flex + add, knee can extend, ankle can dorsiflex, hip tredelenberg, no equinus
  • L5: hip flex (can abduct), knee can extend, ankle can dorsiflex with valgus (peronei +, PT weak), hip and knee normal, hindfoot valgus
  • S1: hip, knee and ankle OK, but claw toes
Q2.At which levels is the ankle in equinus and at which level can it dorsiflex?
  • Equinus at L1-L3
  • Can dorsiflex at L4-L5
  • L5: dorsiflexion with valgus (peronei +, PT weak)
  • L4: no equinus - the slide's 'L4 calcaneus'
Q3.Which levels can extend the knee and which level can walk?
  • Knee flex at L1-L2; can extend from L3 onward
  • L3: can walk (indoor), hip trdelenberg, equinus
Q4.What does the slide title 'L4 calcaneus' refer to?
  • At L4 the ankle can dorsiflex with no equinus (calcaneus deformity)
  • Hip is flex + add with tredelenberg; knee can extend
Q5.Which functional levels have hip flexion with adduction and which can abduct?
  • L2, L3 and L4: hip flex + add
  • L5: hip flex (can abduct)
  • L1: hip ER + F (budda)
Q6.Which levels are Trendelenburg positive and which level has claw toes?
  • L3 and L4: hip Trendelenburg
  • S1: claw toes
▸ Slide 582 · Spine embryologySpine Paed · 5 questions expand
slide 582
Question list
Q1-Q55 questions — tap to reveal all answerslist
  1. What are the three embryological layers and their derivatives in spine development?
  2. When does the neural tube form and what is the metameric shift phenomenon?
  3. How do somites form the vertebral column?
  4. What is the timeline of spinal ossification?
  5. What are the three embryological layers involved in spine development?
Answers · Q & A
Q1.What are the three embryological layers and their derivatives in spine development?
  • Ectoderm infolds at the midline to form the neural tube (CNS precursor)
  • Neural crest cells dorsal to the neural tube become the PNS
  • Mesoderm forms the notochord, which induces neurulation and becomes the nucleus pulposus
Q2.When does the neural tube form and what is the metameric shift phenomenon?
  • At 3 weeks the ectoderm aggregates at the midline and infolds to form the neural tube
  • PNS migrates between each level of somite = metameric shift phenomenon
Q3.How do somites form the vertebral column?
  • At 4 weeks paraxial mesoderm aggregates at the midline to form somites: dermatome, myotome, sclerotome
  • Somites unite around the notochord to form the vertebral body and around the neural tube to form the neural arch
  • Each somite forms one disc plus the adjoining cranial and caudal halves of the vertebra
  • The central part undergoes apoptosis to form the disc
  • von Ebner fissure = separation fissure of a single somite
Q4.What is the timeline of spinal ossification?
  • 6 weeks: chondrification of the spine
  • 9 weeks: primary ossification centres - 1 at the body, 2 at the neural arch
  • 2-6 years: arches fuse with the body
  • 12 years: secondary ossification centres appear at spinous process, transverse process and apophyseal rings
  • 25 years: secondary centres fuse with the primary centres
Q5.What are the three embryological layers involved in spine development?
  • Ectoderm, mesoderm and endoderm
  • Ectoderm infolds at the midline to form the neural tube (CNS precursor); neural crest becomes the PNS
  • Mesoderm forms the notochord, which induces neurulation and becomes the nucleus pulposus
▸ Slide 583 · Scheurmann kyphosisSpine Paed · 12 questions 1 check expand
slide 583
Question list
Q1-Q1212 questions — tap to reveal all answerslist
  1. What are the Sorensen criteria for Scheuermann's kyphosis?
  2. What is the epidemiology and pathophysiology of Scheuermann's kyphosis?
  3. What are the pathology and associations of Scheuermann's kyphosis?
  4. What are the differential diagnoses of thoracic hyperkyphosis?
  5. How is Scheuermann's kyphosis investigated?
  6. What are the symptoms of Scheuermann's kyphosis?
  7. What are the clinical findings of Scheuermann's kyphosis?
  8. What is the conservative treatment of Scheuermann's kyphosis?
  9. What is the operative treatment of Scheuermann's kyphosis?
  10. When is anterior release needed in Scheuermann's kyphosis?
  11. What is the limit of correction in Scheuermann's kyphosis surgery?
  12. What is a Schmorl node?
Answers · Q & A
Q1.What are the Sorensen criteria for Scheuermann's kyphosis?
  • Rigid thoracic hyperkyphosis >45 degrees (normal 20-45 degrees)
  • Anterior wedging >5 degrees in 3 consecutive vertebrae
  • Irregular endplates
Q2.What is the epidemiology and pathophysiology of Scheuermann's kyphosis?
  • Male > female
  • Autosomal dominant inheritance, high penetrance with variable expression
  • Distribution thoracic > thoracolumbar > lumbar
  • Ring apophysis necrosis (occurs at age 12)
  • Cartilaginous endplate mechanical weakening
Q3.What are the pathology and associations of Scheuermann's kyphosis?
  • Thickened ALL, narrowed vertebral disc, wedged vertebral bodies
  • Collagen-to-proteoglycan ratio in the endplate matrix is below normal, causing abnormal end plate ossification
  • Spinal associations: spondylolysis and scoliosis
  • Pulmonary compromise
Q4.What are the differential diagnoses of thoracic hyperkyphosis?
  • Postural
  • Compensation for lumbar spondylolisthesis
  • Congenital (NF dystrophic curve)
  • Infection/ tumour
Q5.How is Scheuermann's kyphosis investigated?
  • X-ray: consecutive anterior wedging, endplate irregularity, disc narrowing, spondylolysis and scoliosis
  • Supine hyperextension fulcrum view: rules out postural kyphosis and aids preop planning; <50% correction needs anterior release
  • MRI for disc pathology, cord compression, epidural cyst and spinal stenosis
  • Ask for hyperextension X-ray to see whether the kyphosis is rigid
Q6.What are the symptoms of Scheuermann's kyphosis?
  • Thoracic/lumbar pain (compensatory hyperlordosis)
  • Pulmonary compromise in severe kyphosis
  • Cosmesis
  • Ataxic gait
  • Knee FFC
Q7.What are the clinical findings of Scheuermann's kyphosis?
  • Thoracic kyphosis + compensatory lumbar hyperlordosis
  • Tight hamstring
  • Neurological deficits are rare
Q8.What is the conservative treatment of Scheuermann's kyphosis?
  • Physiotherapy for stretching if kyphosis <60 degrees
  • Hyperextension brace - controversial in a growing patient
Q9.What is the operative treatment of Scheuermann's kyphosis?
  • PSF +/- Smith-Peterson osteotomy for >75 degrees, neurological deficit or severe pain
  • Posterior approach advantages: less blood loss and reduced surgical time
  • Posterior approach disadvantage: higher rate of pseudoarthrosis
Q10.When is anterior release needed in Scheuermann's kyphosis?
  • When the deformity does not correct to <50 degrees on hyperextension lateral views
Q11.What is the limit of correction in Scheuermann's kyphosis surgery?
  • Do not correct more than 50% of the original deformity
  • Prevents junctional kyphosis or cord compression
Q12.What is a Schmorl node?
  • Herniation of IVD into the vertebral endplate
  • Associated with degeneration
  • 16% prevalence in SE Asia
Fact check

Sorensen criteria for Scheuermann's kyphosis require rigid thoracic hyperkyphosis >45 degrees — contested threshold — Most sources (Radiopaedia, StatPearls) quote the Sorensen kyphosis threshold as >40 degrees (normal 20-40); some texts use >45. The >5 degree wedging in 3 consecutive vertebrae is agreed. — medium confidence — source