CIFOSE DE SCHEUERMANN PDF
Scheuermann disease, also known as juvenile kyphosis, juvenile discogenic disease 11, or vertebral epiphysitis, is a common condition which results in. Scheuermann’s disease is a self-limiting skeletal disorder of childhood. Scheuermann’s .. vertebral column. Hidden categories: CS1 Danish-language sources (da) · Infobox medical condition (new) · Commons category link is on Wikidata. A cifose de Scheuermann é a forma mais clássica de dorso curvo e é o resultado do acunhamento vertebral que ocorre durante a adolescência. Nos adultos, a.
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InHolger Scheuermann described a kyphotic juvenile vertebral alteration that could be distinguished from postural kyphosis based on its peculiar rigidity 1. He observed that the kyphotic deformity was rigid, and associated with wedging of vertebral bodies 2. Diagnostic criteria were established in by Sorensen, who came up with a definition of Scheuermann’s kyphosis SK as a rigid kyphosis that includes three adjacent vertebrae, scheuefmann wedging of five or more degrees 2.
InDrummond suggested that the diagnosis of the disease be based on adjacent wedging of two or more vertebrae 5.
According to literature, the incidence of SK ranges from 0. It is a deformity that schsuermann occurs at the end of juvenile age, more commonly between eight and scheuerman years, and occurs in its most scheueramnn form between 12 and 16 years of age.
The majority of studies do not show any difference between the sexes, and the incidence in men and women is similar, varying only in terms of the criteria for inclusion of each trial 14, The treatment for SK is still controversial.
Isolated posterior arthrodesis presented significant failures, perhaps due to the lack scheuermqnn anterior support, inadequate initial correction, failure of the implant, fixation on the side of the tension, or due to insufficient length of the fixation 12, To resolve these problems, dual approach arthrodesis was proposed, with discectomy, release of the anterior-posterior longitudinal ligament, and intersomatic arthrodesis in the first phase of surgery, and arthrodesis and instrumentation in the second phase.
All the patients were submitted to surgical treatment by the same team of surgeons. The proposed study was submitted to, and accepted by the Research Ethics Committee protocol no. The patients were given instructions and signed a term of consent before taking part in the study. The diagnostic criteria scheurmann SK used were: The indications for d were: Patients with flexible thoracic kyphoses, evaluated by means of physical examination and radiography in hyperextension, were excluded, as were patients with kyphosis of other causes.
Due to the wide variation in prevalence of the deformity between populations, and the lack of studies comparing forms of treatment, sample calculation was not possible. Therefore, we opted to use a sample projected to a work of greater international importance, involving 39 patients, which was conducted partly retrospectively and partly prospectively, and published in by Lee et al Our scheermann consisted of 28 patients, divided into two groups, and operated at different times.
At the end, the two groups were compared, adopting a comparative, case control methodology with transversal analysis.
The age bracket in this group was 13 to 35 years, with a mean age of 19 years; Follow-up time ranged from The ages ranged from 16 to 51 years, with a mean age of The follow-up time ranged from 13 to 31 months, with a mean of The distribution of the groups by sex and age is shown in Table 1.
In the selection of the levels of instrumentation, we considered the proximal level as the vertebra that represented the thoracic kyphosis transition with the cervical lordosis, generally T2 or T3, and the distal level of fusion as the most proximal vertebra that touched the posterior sacral vertebral line, generally from L1 to L3. The patients in the first group were submitted to anterior release by conventional thoracotomy and intersomatic fusion, followed by posterior arthrodesis with posterior instrumentation using the system of pedicle screws.
The anterior approach was performed by means of left thoracotomy with the patient positioned in right lateral decubitus with costectomy, anterior release ve and posterior csheuermann ligamentcomplete discectomy at the maximum levels necessary and intersomatic arthrodesis without instrumentation of an average of seven discs at the site of the deformity.
Only resected rib grafts were placed in the disc spaces. After an average of seven days, the patients were submitted to the second surgery, when third generation posterior instrumentation was performed with autologous graft from spinous, transverse and laminous processes.
With the patient in ventral decubitus, after a posterior access and subperiosteal dissection, resection of the lower facets was performed at all the levels of arthrodesis Figure 2.
The intersection of the upper border of the transverse process and the lateral cfiose line of the upper articular facet was used as the point of insertion of the pedicle screw A flexible probe was used to scheuemrann the presence of bone in the upper, lower, medial, lateral walls and at the end of the access route The screws were then introduced using the freehand technique – unlike the method reported by Kim et al 23 in which a drill was used to make the access route Screws were placed bilaterally or unilaterally at each level.
The position of the screws was checked by radiographic study in lateral and anterior-posterior views.
Scheuermann’s disease – Wikipedia
Using the “cantilever” manoeuvre, the deformity was reduced and the stems were fixed in the distal segments. Compression manoeuvres were used in the apex of the curve. The number of transversal devices varied as necessary during surgery. In the second group, the instrumentation was performed with posterior arthrodesis, where the difference was due to the osteotomies performed at the apex of the deformity of an average of five segments. After performing the posterior closing-wedge Smith-Petersen osteotomies in the segments of the apex of the deformity, the stems were moulded and the deformity was corrected by the same “cantilever” manoeuvre, with compression at the level of the apex Figure 3.
No somatosensitive monitoring studies or evoked medullary potential studies were carried out in any of the cases due to the lack of available conditions for their performance.
All the patients who did not have access to monitoring were submitted to the Stagnara wake-up test, after reduction of the deformity. No orthopedic brace was used on the patients in the postoperative period. The patients were followed up every 15 days in the first month after surgery. New evaluations were carried out at three, six, and twelve months after surgery.
The evaluations were carried out by members of the team, and consisted of a medical examination and questionnaires to evaluate pain, by the visual analogue scale VASthe patients’ satisfaction with the procedure, and any complications.
The radiological exams were executed for each outpatient control follow-up visit, according to indication. For the decision as to which statistical tests to perform, the normality of the variables was tested, i.
With an error of five percent, the variables sex, initial kyphosis, final kyphosis, correction degrees and follow-up months followed a normal distribution. The variables age, level of posterior fusion, and number of screws did not follow this behaviour. Thus, for the variables that were considered normal, a parametric test will be used, in this case, the T-test, to test whether there is any difference between the means of the variables.
For the non-normal variables, a nonparametric test will be used, the Mann-Whitney test. The purpose of this treatment is to level out the sample and avoid any statistical bias. The comparison between the degree of initial and final average kyphosis between the sexes of both groups is shown in table 2. After the posterior approach, an average correction of Of the patients in the first group, 17 had preoperative pain. The average score obtained in the preoperative evaluation was 6.
After follow-up, the patients were evaluated by the same VAS method; only three patients complained of residual pain, and the average postoperative score was 0. In the second group, eight patients presented preoperative pain, with an average score of 5. After the follow-up, only one patient complained of residual pain, and the final average score was 0.
In terms of patient satisfaction with the surgical procedure, In terms of complications associated with the procedures, the following were identified for the first group: The second group presented a case of residual pain of lesser intensity than in the preoperative period, one case of seroma in the postoperative period, improving with local measures, and one case of discomfort at the site of the implants, opting to remove them two years after the procedure, with resolution of the pain.
Since Bradford et al 24 carried out the first report on posterior fusion in the treatment of SK, the surgical indications, as well as the operating techniques, have altered significantly.
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In various case series, pain and deformity are adopted as the criteria for surgical indication 4,22, Some studies indicate surgery for cases of pain that is refractory to conservative treatment 25, Murray et al 15 reserve the surgical option only for cases of unacceptable pain and deformity.
The criteria used in this study were in keeping with literature. The efficacy of combined treatment of SK by the anterior and posterior route is well documented in literature. Lowe 25 analyzed 24 patients submitted to the anterior approach with posterior fusion, and obtained good results without significant loss of correction or complications at the end of the month follow-up. In our study, we retrospectively operated on 19 patients with initial average kyphosis of In relation to the posterior approach in isolation, the debate still continues, as the results of literature are conflicting.
The first reports came from Bradford et al 14 ; but with loss of good results of correction in 16 of the 22 patients. There was no difference in the correction obtained after surgery or after end of the follow-up.
In the present study, the patients in whom the posterior approach was used had a mean follow-up of Two other studies evaluating the posterior approach using the hook system showed loosening of the hooks in three cases out of 27, requiring two subsequent surgeries 4 ; in the other study, there was breaking of the stem in one case out of 30, requiring revision surgery and resulting in one patient with loss of correction, and pain In the series of Lee et al 20 there were no complications related to the instrumentation.
In our series, we demonstrated seven complications in the group in which the double approach was used one case of early surface infection of the surgery wound; one case of asymptomatic breaking of two screws; on case of late infection 24 months after surgery; one case of loosening of the distal implant; and three patients with complaints of residual scheuerrmannand only three in the group in which the posterior route was used one case of residual pain, another of discomfort around the implants, and another with a wound seroma after surgery.
The frequency of complications varies depending on scheuerjann criteria adopted by the researchers, but this has not been validated. This may be explained by the learning curve required for the new cjfose, the incipient number of patients in which the second technique was used, and perhaps, the presence of older patients, with more rigid curves, in the posterior approach group. Although not tested statistically, there was a higher absolute number of complications, though less severe, in group I, with higher levels of satisfaction achieved in group II.
No valid questionnaire of satisfaction and improvement in quality of life was applied in this study; however, for the next follow-up, the SRS questionnaire will be applied. The results of this study demonstrate dcheuermann importance of study with randomized, prospective follow-up with greater homogenization of the dd, to adequately determine which is the best choice in terms of approach.
However, these choices are hampered by the minor prevalence of the disease, and the restricted criteria for surgical indication.
The posterior approach associated with osteotomies has been a recent option, given the association between technical improvements osteotomies and the development of fixation systems, scheusrmann in shorter surgery dd, and fewer comorbidities cifpse associated complications blood transfusion, decrease in pulmonary capacitance, hospitalization times, and recovery times.
The objective of any correction is to offer the patient an improvement in sagittal and coronal balance, centralizing the whole segment above the pelvis, and this has been achieved by means of a single approach. Although there was no ciffose control in this study, it was noted that there were less systemic repercussions in patients when this approach route was used, with faster, less painful rehabilitation.
We highlight the fact that the sample is still small, and the need for longer follow-up of cases, following surgery, as well as better training in the practice of osteotomies, and new studies to evaluate the real role of posterior instrumentation associated with Smith- Petersen osteotomy as a method of treating SK.
In the present study, we observed greater correction of the deformity with the double approach, while in the second group there were better results in the VAS pain scale, and a lower percentage of complications. For a more viable result, a program of prospective, randomized work is needed, to homogenize the groups and eliminate differences in the sample.
Stoddasd A, Osborn JF. Scheuermann’s disease or spinal osteochondrosis: J Bone Joint Surg Br. Surgical management of thoracic cifoxe in adolescents.
Scheuermann disease | Radiology Reference Article |
J Bone Joint Surg Am. Moe’s textbook of scoliosis cofose other spinal deformities. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. Vertebral bone density in Scheuermann disease.