Orthotic Management of The Problematic Scoliosis
Siegfried W. Paul, C.P.O. *
This Paper was prepared for and presented at the 1970 Assembly of Interbor in Turin, Italy.
A study of 135 patients under treatment with the Milwaukee Orthosis conducted two years ago revealed excellent results which are to be expected for the properly treated case. Missing in my presentation as well as in most known publications was a discussion of the Problematic Case, i.e., those patients which require the fullest attention of all of the members of a "Scoliosis Team."
The Scoliosis Clinic at Newington Children's Hospital has seen a most dramatic increase in its patient load. A previous study was based on 135 patients, we now would have to discuss over 600 patients in a similar paper.
Today, I shall discuss some of these Problematic Cases and our concepts of treatment at Newington.
The initial diagnosis of Scoliosis will place the patient in one of three major categories. The idiopathic, paralytic, and juvenile scoliosis. Problematic cure patterns are most frequently seen in the paralytic and juvenile groups.
Problematic idiopathic curves are basically related to the following circumstances: A rigid lumbar curve, severe pelvic obliquity, the, high thoracic lordosis observed in conjunction with a narrow A-P diameter of the chest and the high thoracic curve with rotation of vertebral bodies.
Paralytic scoliosis results in the most severe structural changes which are secondary to cerebral palsy, polio, and lower motor neuron disturbances.
The congenital and juvenile scoliosis cases demand our special attention since problems primarily due to scoliosis easily shadow the spinal problem. Scoliosis is frequently seen secondary to neurofibromatosis, amyotonia congenita, Wernig Hoffmans disease, osteogenesis imperfecta, arthrogryposis, hemivetebra, Marphans syndrome, and Ehlers-Danlos syndrome.
Fig. 1
Our basic approaches to these problems can be summarized as follows:
The idiopathic curve is ordinarily treated according to concepts outlined by Drs. Schmid, Blount, and Moe. Although the purpose of this presentation is not to discuss the Milwaukee routine, I would like to show the functional Milwaukee orthosis as applied at Newington.
As you will recall, careful placement of the pressure pads will result in a three-point pressure system aided by the distraction from pelvic and head support. The problematic curve will require precise arrangement of this pressure system.
The rigid lumbar curve should be first treated with a localizer cast in an attempt to loosen the structure of the curve.
The Milwaukee orthosis with a pelvic section fitted tight on the side of the curve and loose on the opposite side with a functional lumbar pad and pressure coordinating components will be most effective in stabalizing and balancing of the curves.
The Orthotist can do little for the patient with a severe pelvic obliquity. A level pelvis is mandatory for the proper fit of the Milwaukee orthosis and a shoe lift will frequently establish this prerequisite.
The high thoracic lordosis in conjunction with a narrow chest is treated with anterior pressure pads in addition to the routine pressure system. Exercises intended to expand the chest are also helpful.
High thoracic primary curves with severe rotation respond to a shoulder flange.
Fig. 2
This shoulder ring flange will actively derotate the veterbral bodies as well as control the high thoracic curve. Over-correction is possible at this level and application of an L-shaped pad replacing the ring flange will be indicated.
The L-shaped pad excludes the shoulder girdle but includes the scapula, exerting greater lateral force than the regular thoracic pad.
Fig. 3
Our primary objective for the severe paralytic scoliosis patient is to achieve a cosmetically acceptable, functional correction and to maintain this correction. Severe paralytic curves will not stabilize with bony maturity and spinal fusions will be performed once bony maturity has been reached.
Fig. 4, Fig. 5, Fig. 6
The Following Cases Will Demonstrate This Approach
Case No. 1: This is a 17-year-old boy who was first seen in 1957. He is a post-polio patient.
Fig. 7 Fig. 8 Fig. 9
His severe curve was treated in localizers for two years. The first Milwaukee orthosis was applied in 1959. A spinal arthrodesis was performed in November 1967 and the orthosis continued till June 1969. This patient was fitted with three orthoses during this 10-year period. His curve was improved and today's clinical examination demonstrates a cosmetically acceptable result.
The next patient is a twenty-year-old female who was diagnosed as amyotonia congenita with secondary scoliosis. This patient is a good example for a case where an error in judgement led us to do too little too late. The patient was ambulatory till age seven at which time the scoliosis became decompensated. Early holding of the curve was attempted with corsets, followed by an early version of the Milwaukee orthosis. A Harrington instrumentation was utilized two years ago. She is now a wheel chair patient who is gainfully employed.
Fig. 10, Fig. 11, Fig. 12, Fig. 13
Our congenital and juvenile groups benefit from an early treatment which is mandatory in order to prevent additional deformities. Plastic anterior or posterior body shells fabricated from vitrathene, a polythene plastic, have proven to be most effective. The lower motor neuron disturbed patient will go into extensive orthotic management to become ambulatory.
Fig. 14 Fig. 15, Fig. 16, Fig. 17, Fig. 18, Fig. 19, Fig. 20, Fig. 21 Fig. 22
Less involved patients will go into the Newington infantile scoliosis splint or a spinal corset. A Milwaukee orthosis will be indicated once tne more mature age of 4 to 6 years, depending on growth, has been reached.
Fig. 23, Fig. 24
The next patient is a good example for this type of treatment. This patient is an 11-year-old boy afflicted with Marphans syndroms.
The initial application of a Milwaukee orthosis was at age three, which was somewhat early. However, we have been able to achieve corrections of his curves and have avoided more severe deformity. He is now wearing his fourth Milwaukee orthosis. Those patients which demonstrate no hope of future ambulation have benefitted from body jackets molded of vitrathene.
Such body jackets have proven to be of help in stabilizing the spine and preventing its collapse.
The amyotonic case was also able to exercise better respiration and the retarded child was easier to manage by its custodians.
Fig. 25, Fig. 26, Fig. 27, Fig. 28
The same applies to the patients
with Werdnig Hoffmans disease, like this patient in a reclining seating device with lateral support.
Conclusion
The examples presented here can only highlight the many problems posed by scoliosis in its multitude of variations. Only the sharing of knowledge obtained by all of us will help to advance our current status of Orthotic Technology in the treatment of scoliosis.
Acknowledgements:
This paper could not have been presented without the assistance and cooperation of the staff of the Newington Children's Hospital.
My special appreciation is extended to Dr. James Hardy, Scoliosis Clinic Chief, Dr. Walter Bonne, Orthopedic Resident, the members of the Photography Department, Medical Records, the Radiology Department, and the Staff of my Department.
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