Dropped Head Syndrome: An Update on Etiology and Surgical Management.

¼ Dropped head syndrome is a group of disorders with diverse etiologies involving different anatomical components of the neck, ultimately resulting in a debilitating, flexible, anterior curvature of the cervical spine. ¼ Causes of dropped head syndrome include myasthenia gravis, amyotrophic lateral sclerosis, Parkinson disease, radiation therapy, and cumulative age-related changes. Idiopathic cases have also been reported. ¼ Nonoperative treatment of dropped head syndrome includes orthotic bracing and physical therapy. ¼ Surgical treatment of dropped head syndrome consists of cervical spine fusion to correct the deformity. ¼ The limited data available examining the clinical and radiographic outcomes of surgical intervention indicate a higher rate of complications with the majority having favorable outcomes in the long term.

Brace Success Is Related to Curve Type in Patients with Adolescent Idiopathic Scoliosis.

BACKGROUND: Curve magnitude and skeletal maturity are important factors in determining the efficacy of bracing for the treatment of adolescent idiopathic scoliosis, but curve morphology may also affect brace success. The purpose of this study was to determine the influence of curve morphology on the response to bracing with a thoracolumbosacral orthosis (TLSO). METHODS: A retrospective review of patients managed with an orthosis for the treatment of adolescent idiopathic scoliosis who were prospectively enrolled at the initiation of brace wear and followed through completion of bracing or surgery was performed. Inclusion criteria were main curves of 25° to 45° and a Risser stage of 0, 1, or 2 at the time of brace prescription. Compliance with bracing was measured with Maxim Integrated Thermochrons. Radiographs made at brace initiation, brace cessation, and final follow-up were used to retrospectively categorize curves with use of the modified Lenke (mLenke) classification system and more broadly to categorize them as main thoracic or main lumbar. The effect of morphology on outcome was evaluated using chi-square and Fisher exact tests. RESULTS: One hundred and sixty-eight patients were included. There was no difference in curve magnitude at the time of brace initiation (p = 0.798) or in average hours of daily brace wear (p = 0.146) between groups. The rate of surgery or progression of the curve to ≥50° was 34.5% (29 of 84) in mLenke-I curves, 54.5% (6 of 11) in mLenke-II curves, 29.4% (10 of 34) in mLenke-III curves, 17.6% (3 of 17) in mLenke-V curves, and 13.6% (3 of 22) in mLenke-VI curves. There were no mLenke-IV curves at the time of brace initiation. The rate of surgery or progression to ≥50° was 34.1% (44 of 129) in the combined thoracic group and 15.4% (6 of 39) in the combined lumbar group (p = 0.0277). In brace-compliant patients (>12.9 hours/day), the rate of surgery or progression to ≥50° was 30.3% (20 of 66) in main thoracic curves and 5.3% (1 of 19) in main lumbar curves (p = 0.0239). One-tenth of curves changed morphology during bracing. The rate of surgery or progression to ≥50° was 35.8% (43 of 120) in persistent main thoracic curves, 20.0% (6 of 30) in persistent main lumbar curves, 12.5% (1 of 8) in main thoracic curves that became main lumbar curves, and 0% (0 of 9) in main lumbar curves that became main thoracic curves (p = 0.0383). CONCLUSIONS: Thoracic curves are at greater risk for brace failure than lumbar curves are despite similar initial curve magnitudes and average amount of daily brace wear. A change in curve pattern may imply flexibility and is associated with brace success. Patients with thoracic curves should be counseled accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Successful management of iliocostal impingement syndrome: A case series.

BACKGROUND: Iliocostal impingement syndrome is a rare, painful, and disabling condition associated with thoracic hyperkyphosis and kyphoscoliosis. There is little published literature regarding management of this syndrome. The purpose of this case series is to report treatment outcomes for iliocostal impingement syndrome with improving posture and back muscle strength. CASE DESCRIPTION AND METHODS: Thirty-eight women with thoracic hyperkyphosis or kyphoscoliosis and back and/or flank pain were diagnosed with iliocostal impingement syndrome on the basis of symptoms and spine radiographs. They were instructed in weighted kypho-orthosis use and taught a home back-extensor strengthening program. Outcome measures included posture evaluation and pain level. FINDINGS AND OUTCOMES: All patients reported immediate pain reduction with weighted kypho-orthosis trial. Nineteen patients returned within 2 years, and all had continued pain relief and posture improvement. CONCLUSIONS: Our findings suggest that successful management of iliocostal impingement syndrome is possible with a weighted kypho-orthosis and back strengthening program focusing on posture improvement. CLINICAL RELEVANCE: Iliocostal syndrome is a rare, painful, and disabling condition that severely affects quality of life. This report discusses our diagnostic and treatment approach to this syndrome, which has proven successful in our patient population.

Bandagem elástica terapêutica na dor e no equilíbrio de indivíduos com alteração postural / Therapeutic elastic bandage on pain and balance of individuals with postural change

Introdução: Alterações posturais modificam o equilíbrio e a estabilidade, sobrecarregando estruturas corporais e resultando em dor. A Fisioterapia vem utilizando bandagens como auxílio em suas condutas. Objetivo: Analisar os efeitos da bandagem na dor e equilíbrio de participantes com hipercifose torácica e protusão de ombro. Métodos: Dez participantes com protração de ombros, hipercifose torácica e dor musculoesquelética na região torácica tiveram seus valores de dor e oscilação corporal avaliados por meio de fichas e estabilometria. Posteriormente, aplicaram-se bandagens para correção postural e após sete dias realizou-se uma reavaliação. Resultados: Houve diminuição significativa na dor (p=0,0001) e apenas redução mínima das oscilações posturais dos participantes. Conclusão: A bandagem mostrou-se benéfica somente na dor, enquanto no equilíbrio ela foi insuficiente. Sugerem-se novos estudos com diferente casuística para verificar se a bandagem realmente funciona como terapia ou se promove apenas efeito placebo.

Introduction: Postural changes modify the balance and the stability, overloading body structures and resulting in pain. Physiotherapy has been using bandages as support in their conduct. Objective: To analyze the effects of bandage in pain and balance of participants with thoracic kyphosis and shoulder protrusion. Methods: Ten participants with protraction of shoulders, thoracic hyperkyphosis and musculoskeletal pain in thoracic region had their values of pain and body oscillation assessed through of forms and stabilometry. Posteriorly bandages were applied for postural correction and after seven days a revaluation was performed. Results: Significant decrease in pain (p = 0.0001) and only minimal reduction of postural oscillations of the participants were observed. Conclusion: The bandage showed to be beneficial only in pain, while on the balance was insufficient. We suggest new studies of other case histories to verify whether the bandage really works as therapy or if it only promotes a placebo effect.

Improvement of spinal alignment and quality of life after corrective surgery for spinal kyphosis in patients with osteoporosis: a comparative study with non-operated patients.

UNLABELLED: This study evaluated changes in spinal alignment and quality of life (QOL) after corrective spinal surgery for patients with postmenopausal osteoporosis and spinal kyphosis. Spinal global alignment and QOL were significantly improved after corrective spinal surgery but did not reach the level of non-operated controls. INTRODUCTION: With the increased aging of society, the demand for corrective spinal instrumentation for spinal kyphosis in osteoporotic patients is increasing. However, previous studies have not focused on the improvement of quality of life (QOL) after corrective spinal surgery in patients with osteoporosis, compared to non-operated control patients. The purposes of this study were thus to evaluate changes in spinal alignment and QOL after corrective spinal instrumentation for patients with osteoporosis and spinal kyphosis and to compare these results with non-operated patients. METHODS: Participants comprised 39 patients with postmenopausal osteoporosis ≥50 years old who underwent corrective spinal surgery using multilevel posterior lumbar interbody fusion (PLIF) for symptomatic thoracolumbar or lumbar kyphosis, and 82 age-matched patients with postmenopausal osteoporosis without prevalent vertebral fractures. Spinopelvic parameters were evaluated with standing lateral spine radiography, and QOL was evaluated with the Japanese Osteoporosis QOL Questionnaire (JOQOL), SF-36, and Roland-Morris Disability Questionnaire (RDQ). RESULTS: Lumbar kyphosis angle, sagittal vertical axis, and pelvic tilt were significantly improved postoperatively. QOL evaluated with all three questionnaires also significantly improved after 6 months postoperatively, particularly in domain and subscale scores for pain and general/mental health. However, these radiographic parameters, total JOQOL score, SF-36 physical component summary score, and RDQ score were significantly inferior compared with non-operated controls. CONCLUSIONS: The results indicate that spinal global alignment and QOL were significantly improved after corrective spinal surgery using multilevel PLIF for patients with osteoporosis and spinal kyphosis but did not reach the level of non-operated controls.

Effects of selected forms of physical activity on body posture in the sagittal plane in women post breast cancer treatment.

BACKGROUND: Breast cancer treatment may be a cause of postural disorders. OBJECTIVE: Assessment of the effects of various forms of physical activity on body posture in the sagittal plane in women post breast cancer treatment. STUDY GROUP: Sixty women who had received breast cancer treatment. The study group was intentionally divided into three groups of 20 women who followed different exercise regimens: NordicWalking (NW), water resistance exercise (WE) or general fitness exercise (GE). METHODS: Photogrammetric examination of body posture using a Computer-Based Body Posture Diagnostics apparatus performed at baseline and after an 8-week regimen of appropriately selected physical exercise. RESULTS: A favourable tendency for the shallowing of thoracic kyphosis and the reduction of lumbar cu rvature of the spine was noted in the NW group. Reduced kyphosis was also noted in the WE group, however it was accompanied by more pronounced lumbar lordosis and a tendency for excessive forward bending of the trunk. In the GE group, on the other hand, no significant differences were observed in terms of the shape of anteroposterior spinal curvatures. CONCLUSIONS: The diversity observed in the shape of anteroposterior spinal curvatures following physical training regimens of different type and nature demonstrates the need of appropriate exercise selection to attain the desired therapeutic outcome. Balanced postural changes were only identified among the women in the NW group. In the GE group, however, training only sustained the status existing prior to the initiation of the exercise regimen.

Body posture of women after breast cancer treatment.

INTRODUCTION: Human body posture changes in the course of ontogenesis. The changes are brought about by both internal factors (illness) and external factors (injury). The negative consequences of a medical condition such as breast cancer, together with the treatment process, undoubtedly contribute to disturbance of body posture. The aim of this paper was to evaluate the type of body posture in women after treatment of breast cancer on the basis of anteroposterior spinal curves. MATERIAL AND METHOD: The study involved a group of 51 (Group 1) women following treatment of breast cancer and a group of 37 healthy women (Group 2). The average age of the women in Group 1 was 61 years, and the average age of the healthy women was 58 years. All participants underwent a photogrammetric examination of body posture. Postural types were defined on the basis of the value of a compensation index (µ) as kyphotic, balanced, and lordotic. The following subtypes were distinguished within these three categories, depending on the shape of the spinal curves: kyphotic subtype I, II, III; balanced subtype I, II, III; and lordotic subtype I, II, III. RESULTS: The post-mastectomy group and the control group did not differ with regard to age (p=0.09), making it possible to continue the analysis of postural differences, which revealed significant differences at p=0.00008. In the group of women after treatment of breast cancer, 82.3% demonstrated a faulty body posture, compared to only 35.1% of the controls. There was no significant relationship between the quality of body posture and oncological treatment. CONCLUSION: A significantly higher incidence of faulty body postures was observed among women after treatment of breast cancer.

[Orthotic methods for osteoporosis and osteoporotic vertebral fracture]. / Orthesenversorgung bei Osteoporose und osteoporotischen Wirbelkörperfrakturen.

Even in times of kyphoplasty and vertebroplasty, braces remain an efficient option in the treatment of osteoporotic hyperkyphosis due to imminent or manifest vertebral wedging with the obligatory pain and fracture risk of adjacent vertebraes. In the same fashion, acute osteoporotic fractures with considerable backpain can be treated with an adequate orthosis besides analgetics and osteological drugs. Essential is the careful selection of the right brace for a given type of osteoporotic fracture: Overall brace-frames (Stagnara type) should be used only in highly unstable or multiple osteoporotic fractures with impact onto the spinal canal where surgery is not possible. These brace frames should be administered only for the shortest possible period (8-12 weeks) to reduce muscle atrophy and immobilization. However, in the typical stable osteoporotic wedge fracture, light weight constructions like the Jewett or Bähler-Vogt brace or - in less severe cases - dynamic braces (e.g. TorsoStretch brace or SpinoMedActive brace) should be used to minimize muscle atrophy and demineralisation. Brace treatment at its best though, can be only one step in the cascade of measures to fight demineralisation and the clinical consequences: General physiotherapy, analgetics and specific osteological drugs and minerals add essentially to the treatment.

Rehabilitation using manual mobilization for thoracic kyphosis in elderly postmenopausal patients with osteoporosis.

OBJECTIVE: To explore the feasibility and effects of rehabilitation using manual mobilization of the thoracic spine in elderly female patients with osteoporosis. METHODS: Forty-eight postmenopausal patients with osteoporosis (age 76 -/+ 7 years) were randomly assigned to 3 months rehabilitation (18 sessions including manual mobilization, taping and exercises, n = 29) or control (wait-list, n = 19). The primary outcome was thoracic kyphosis degree (Spinal-Mouse). Secondary outcomes were back pain (visual analogue scale) and quality of life (Qualeffo-41). Explanatory outcomes were compliance with rehabilitation, complications, and patients' and therapists' perceptions regarding the rehabilitation programme. RESULTS: Thoracic kyphosis improved significantly following rehabilitation compared with controls (intention-to-treat analysis, p = 0.017); and in patients who were compliant with rehabilitation (n = 15) compared with those who were non-compliant (p = 0.002) and controls (p = 0.001). Mental health worsened slightly in the rehabilitation group (p = 0.029), but not significantly compared with controls. Neither patients nor physical therapists reported serious adverse effects. CONCLUSION: Three months of rehabilitation with manual mobilization can attenuate thoracic kyphosis in elderly patients with osteoporosis. Its impact on back pain and quality of life remains unclear and needs further investigation.

Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease.

An increase of the physiological kyphosis during growth is defined hyperkyphosis (HK) and, according to the level where the apex of the curve can be retrieved, we can distinguish a thoracic HK and a thoraco-lumbar one, also called junctional kyphosis. Since these conditions can cause pain and esthetics impairments, lead in adulthood to an higher incidence of spinal and shoulder pain, and evolve during growth, it is important to manage this deformity. The aim of this paper was to present the state of the art about HK and its treatment. Scheuermann Disease (SCHK) is the better known cause of HK; other causes can be idiopathic or postural, trunk extensor muscles weakness or neurological problems. Despite etiology a specific treatment can be required during growth to prevent evolution and reach a better spinal alignment in adulthood. It is at the base of treatment and allow monitoring. There are some validated methods that can be used in a comprehensive rehabilitation approach. Evidence in this field is scanty, even if there is quite a consensus on possible treatments. They aim at improving posture and esthetics, and abolishing pain; they include: exercises, used mainly in mobile postural/idiopathic HK, and in SCHK without HK; braces (plus exercises, in this case aimed at reducing brace impairments), that in rigid HK and in most of SCHK patients also allow a better vertebral growth; surgery could be used in worst cases, even if it should be carefully considered, because it requires fusion and loss of spinal function.

[Congenital cervical vertebral dysmorphism. Syndromatic integration through radiological clinical correlation]. / Dismorfismo vertebral cervical congénito. Integración sindromática mediante correlación clínica-radiológica.

Cervical spine dysmorphisms (CSD) occurs in an heterogeneous group of patients unified by the presence of congenital defects result from malalignment, formation or segmentation of the cervical spine; generating disability. This problem requires comprehensive evaluation of patients with scoliosis diagnosis, correlating clinical and radiological findings and the presence of numerous abnormalities of other systems in order to give an opportunely syndrome diagnosis and multidisciplinary management of this patients with the aim to give them an integral rehabilitation treatment increasing their quality of life. In this study we described clinical and radiological findings in children with CSD diagnosis. We studied 47 consecutive outpatients of Pediatric Rehabilitation Division in Instituto Nacional de Rehabilitaci6n (INR) with scoliosis diagnosis. Sixteen patients (34%) had CSD diagnosis. Most frequently syndromes (Sx) were: Klippel-Feil Sx (19%), Wildervanck (4.3%), neurofibromatosis (4.3%), Morquio (2.1%), Stickler (2.1%) and Williams (2.1%). We found CSD diagnosis in 34% of group studied, greater than medical literature.

Nonoperative management of osteoporotic vertebral compression fractures.

As the population ages, vertebral compression fractures are an increasing source of pain and dysfunction. The immobilisation that often occurs with fractures can lead to multiple medical complications and their management can be complex as care may require multiple treatment modalities. Each individual responds to pain differently and a treatment plan must be tailored to the individual's pain, functional limitations and goals. The likely first choice for managing stable osteoporotic vertebral compression fractures is conservative management. Treatment options usually involve a combination of medications, bracing and physical therapy. If radicular pain is a component of the pain syndrome, epidural steroid injections may be beneficial. In addition, some patients may benefit from vertebral augmentation. This paper reviews current recommendations for managing vertebral compression fractures. Treatment options including vertebral augmentation are reviewed, including indications and complications.

Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine.

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8 degrees. Loss of correction was maximal in the lumbosacral spine at 13.7 degrees. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.

[The KIL-system for qualitative and quantitative evaluation of posture in lateral view]. / Das KIL-Schema zur qualitativen und quantitativen Beurteilung der Körperhaltung im seitlichen Profil.

AIM: To register also minor variations of posture sa simple and economic procedure should be worked out to categorize posture types concerning quality as well quantity. METHOD: On the Image of the lateral body profile three reference points were determined which allow us to measure two distances and two angles. RESULTS: The relation of the two distances reflects the degree of kyphosis, the angles indicate on the one hand the inclination of the spinal sagittal configuration and on the other hand the degree of lordosis. The measured values are shown in the Kyphosis-Inclination-Lordosis system (KIL system). The components of measurement have proved successful also for static as well as for dynamic posture assessments. The method was simple and economic as postulated. CONCLUSION: The method allowed us to analyse reliably the effect of active primary Intervention also for minor variations in posture on pupils at the age of 11 to 15 over a period of three years. The quantitative analyse made it possible - contrarily to the usual postural types going by what Staffel said - to define subcategories and with it a precise selection of individuals who need a secondary intervention. The method has been set up for check-ups in school, but an application to other groups should be possible.

Tratamento cirúrgico da cifose patológica / Surgical treatment of pathological kyphosis

Foram estudados 13 pacientes com cifose patológica de diferentes etiologias (Doença de Scheuermann, espondilite anquilosante, congênita, tuberculose vertebral, sequela de laminectomia e síndrome de Morquio), que foram submetidos ao tratamento cirúrgico. A cifose pré-operatória variou de 75 a 100 graus (média 73,3 graus) e a média dos valores após o tratamento cirúrgico foi de 42,3 graus. O tipo de tratamento realizado estava relacionado com as características da cifose (raio longo ou curto, flexibilidade e magnitude), e são apresentadas as diferentes técnicas e filosofia de tratamento dos autores para o tratamento cirúrgico dessa modalidade de deformidade vertebral.

Cifose de Scheuermann: resultados precoses com uso de colete de Milwaukee / Scheurmann's kyphosis: early results with use of Milwaukee's brace

Foram avaliados 23 pacientes que apresentavam cifose de Scheuermann, submetidos a tratamento conservador com colete de Milwaukee. A rotina de uso do colete consistiu em: uso integral (23 horas/dia) durante os seis primeiros meses e uso parcial (12 horas/dia) no período subseqüente de tratamento. O tempo total de uso do colete variou de 10 a 23 meses, com média de 14 meses. Quinze pacientes eram do sexo masculino e 8 do sexo feminino, cujas idades variaram de 9,3 a 14,6 anos. Os valores angulares iniciais das curvas estavam compreendidos entre 45 e 62 graus, com média de 51 graus. Após a descontinuaçäo do uso do colete de Milwaukee, os valores iniciais ao tratamento, variando de 29 a 42 graus, com média de 33 graus. O tempo de acompanhamento pós-colete variou de 2 a 27 meses. Baseados em nossos resultados, concluímos que o colete de Milwaukee proporcionou, a curto prazo excelentes resultados no tratamento da cifose de Scheuermann

Postmenopausal spinal osteoporosis: physical therapy and rehabilitation principles.

In this communication the physical therapy and rehabilitation measures utilized in the management of patients with spinal osteoporosis are discussed. The bone loss and the subsequent bone disease that occur in some older persons, and especially in postmenopausal women, call for special physical therapeutic measures. One should be cautious about prescribing exercises, for some may predispose the spine to undue sprain and strain. This principle applies to any exercise program, whether therapeutic or recreational.