Scoliosis English name: Scoliosis Department: Orthopedics Commonly used drugs: Symptoms: Finger, deformity, neurological symptoms, thoracic abnormalities, low back pain Scoliosis, commonly known as scoliosis, is a three-dimensional deformity of the spine that includes serial abnormalities in the coronal, sagittal and axial positions. A normal person’s spine should look like a straight line from the back and be symmetrical on both sides of the trunk. Scoliosis should be suspected if the shoulders are unequal in the frontal view or if the back is uneven from the back. A full spine x-ray in the standing position should be taken at this time, and if the frontal x-ray shows a lateral curvature of the spine greater than 10 degrees, scoliosis is diagnosed. In mild scoliosis, there is usually no significant discomfort and no visible trunk deformity on the exterior. More severe scoliosis can affect the growth and development of infants and adolescents, deforming the body and, in severe cases, affecting cardiopulmonary function and even involving the spinal cord, resulting in paralysis. Mild cases of scoliosis can be observed, while severe cases require surgery. Scoliosis is a common disease that affects adolescents and children, and it is crucial to detect and treat it early. Idiopathic scoliosis (idiopathic seoliosis): refers to scoliosis of unknown origin and is the most common, accounting for about 75% – 80% of scoliosis. There are three types of congenital scoliosis: neuromuscular scoliosis: a deformity of the spine in the coronal plane caused by a lesion in the human neuromuscular conduction pathway. Neurofibromatosis combined with scoliosis: Highly heritable, accounting for about 2% of the total number of cases. Characterized by 6 or more café-au-lait spots on the skin, there may be limited rubbery neuroma. The deformity continues to progress, even after surgery, and is difficult to treat. Abnormal mesenchymal tissue with scoliosis: Commonly seen in Marfan syndrome, which is combined with scoliosis in 4-0 to 75% of patients. Osteochondrogenic dystrophy combined with scoliosis: including curvilinear dwarfism, mucopolysaccharide accumulation disease, etc. Metabolic disorders combined with scoliosis: such as rickets, osteogenesis imperfecta, juvenile osteoporosis, etc. Scoliosis due to contracture of extra-spinal tissues: e.g., scoliosis due to septic chest or post-burn scarring. Other causes of scoliosis: 2. Classification Scoliosis is divided into non-structural scoliosis and structural scoliosis. Non-structural scoliosis: Non-structural scoliosis means that the spine and its supporting tissues are not abnormal, the deformity can be corrected on the lateral bending image or traction image, and the scoliosis can be eliminated after treatment for the cause. Structural scoliosis: Structural scoliosis refers to lateral curvature with fixed rotational structures. The scoliosis cannot be self-corrected by lying down or by lateral bending, or it cannot be maintained despite correction, and the affected vertebrae are fixed in a rotational position. 3. Pathology The etiology of various types of scoliosis is different, but the pathological changes are similar. Changes in the vertebral body and attachments The vertebral body on the concave side of scoliosis is wedge-shaped and rotated. The vertebrae of the main scoliosis are rotated to the concave side. The concave side has a shorter and narrower pedicle, and the vertebral plate is slightly smaller than the convex side. The spinous process rotates and tilts toward the concave side, narrowing the concave spinal canal. The small joints on the concave side thicken and harden to form a bony mass. Changes in the intervertebral disc, muscle-muscle and ligament The vertebral space on the concave side is narrowed, the convex side is widened, and the small muscles on the concave side are mildly contracted. Changes in the rib cage The rotation of the vertebral body causes the rib cage on the convex side to protrude into the posterior back, forming a bulge and, in severe cases, a razorback. The ribs on the convex side are separated from each other and the gap is widened; the ribs on the concave side are crowded together and protrude forward, resulting in asymmetry of the chest. Changes of internal organs Severe deformation of the thorax and deformation of the lung under pressure can cause pulmonary heart disease in serious cases. 4.Clinical manifestation Early deformation is not obvious, often not attract attention. During the growth period, the lateral convexity deformity develops rapidly, and the height can be less than that of the same age, the shoulders are not equal, and the thorax is asymmetrical. In severe cases of scoliosis, razorback deformity may appear, affecting cardiopulmonary development and showing corresponding symptoms of nervous system pulling or compression. 5.Examination Physical examination The body should be fully revealed and the examiner should observe carefully from the front, back and both sides. Pay attention to the presence of skin pigmentation or subcutaneous tissue swelling, and the presence of abnormal hair and cystic material on the back. Note the breast development and whether the thorax is symmetrical. Have the patient bend forward and observe whether his back is symmetrical. If one side is elevated, it indicates a rotational deformity of the rib cage and vertebrae. Observe the symmetry of the two shoulders. Place a plumb line along the spinous process and measure the distance from the hip cleft to the plumb line to observe whether the trunk is out of compensations. Check the range of motion of the spine and the nervous system. Auxiliary examinations: X-ray examination cobb method: most commonly used to determine the upper and lower end vertebrae of the scoliosis spine, the angle of intersection between the plumb line of the upper edge of the cephalic end vertebra and the plumb line of the lower edge of the caudal end vertebra is the (;obb angle. If the upper and lower edges of the terminal vertebrae are unclear, the line of the upper and lower edges of the arch can be taken, and then the angle of intersection of their vertical lines is taken. FergllSOFI method (Figure 72-23): less frequently used to find the midpoint of the terminal vertebra and the parietal vertebral body. Then this vertebral scarf accounted for the upper and lower end vertebral midpoints were drawn two vertical lines, the angle of intersection that is the angle of lateral convexity. Standing full frontal and lateral spine images: This is the basic method for diagnosing scoliosis. The patient must be in the upright position when the film is taken, as muscle relaxation in the recumbent position will result in a reduction in the true degree of scoliosis. The entire spine should be included in the radiograph. Supine maximum left and right bending images, gravity suspension traction images, and fulcrum images are valuable in guiding treatment by understanding the intrinsic flexibility of the scoliosis spine. Stagnara: For patients with severe scoliosis, especially with kyphosis and severe vertebral rotation, it is difficult to see the deformity of the ribs, transverse processes and vertebral bodies on ordinary x-rays, and de-rotation images are needed to understand the true structure of the scoliotic vertebrae. Measurement of lateral convexity: measurement of vertebral rotation (Nash-Moe method) (Figure 72-24): according to the position of the vertebral arch on the orthogonal x-ray, it is divided into 5 degrees. 0 degrees: the arch is symmetrical; I degrees: the convex side of the arch has moved to the midline, but not beyond the first frame, and the concave side of the arch has become smaller; II degrees: the convex side of the arch has moved to the second frame, and the concave side of the arch has disappeared. degree II: the convex side of the arch has moved to the second frame and the concave side of the arch has disappeared; degree III: the convex side of the arch has moved to the center and the concave side of the arch has disappeared; degree IV: the convex side of the arch has crossed the center and is close to the concave side. Special imaging tests Myelography: routine myelography should be performed for congenital scoliosis to exclude deformities of the nervous system. CT: CT scan has obvious superiority in the diagnosis of spine, spinal cord, and nerve root lesions, especially in areas that are not clearly shown by ordinary x-ray (occipital neck, cervicothoracic segment, etc.), and can clearly show the fine structure of vertebrae, intravertebral canal, and paravertebral tissues. In particular, myelography and scanning (CTM) can understand the real situation in the spinal canal and the relationship between bone and spinal cord and nerves, and provide information for surgical treatment. MRI: The discriminatory power of MRI for lesions in the spinal canal not only provides the location and extent of lesions, but also provides better discrimination than CT for their nature such as edema, hematoma, and spinal cord degeneration, etc. However, due to the influence of deformities, MRI examination cannot yet completely replace C’I, or myelography. Pulmonary function tests are routinely performed in patients with scoliosis. Patients with scoliosis have reduced total lung volume and spirometry, while residual air volume is mostly normal, and the reduction in spirometry correlates with the severity of scoliosis. Electrophysiological examinations are important to understand whether scoliosis patients have combined neurological and muscular system disorders. Electromyography: Electromyography can be used to understand the status of motor units and to assess and judge nerve and muscle function. Nerve conduction velocity measurement: Nerve conduction velocity can be divided into motor conduction velocity and sensory conduction velocity. There are many factors affecting the conduction velocity measurement, and if the lesion is unilateral, the healthy side should be used as the control. Evoked potentials: Somatosensory evoked potentials are useful for determining the degree of spinal nerve injury, estimating the prognosis or observing the effect of treatment. Identification of developmental maturity Maturity evaluation is particularly important in the treatment of scoliosis. It must be evaluated comprehensively based on physiological age, actual age, and bone age. The main components include: Bone age of the wrist. x-rays of the wrist can be taken in patients under 20 years of age to help determine the patient’s bone age. Risser’s sign. The epiphyseal ring of the ilium appears sequentially from the anterior superior iliac spine to the posterior superior iliac spine. Risser’s sign is the total length of the epiphyseal ring from the anterior superior iliac spine to the posterior superior iliac spine, which is divided into four equal parts: 0 for no appearance, I° for only 1/4 appearance, II° for 2/4 appearance, III° for 3/4 appearance, IV° for complete appearance, and V° for complete ossification and fusion with the ilium. The epiphysis is the latest epiphysis to close in the whole body and the age of closure is about 24 years. If the Risser sign is V°, it indicates that the spinal bones will no longer develop and the scoliosis deformity will generally no longer progress. Vertebral epiphyseal ring. The fusion of the epiphyseal ring with the vertebral body on a lateral radiograph indicates that the spinal column has stopped growing and is an important sign of epiphyseal maturation. Acetabular Y-shaped cartilage. If the Y-shaped cartilage of the acetabulum is closed, this indicates that spinal growth is nearing cessation. Secondary sexual characteristics: Note the change of voice in boys, the first menstruation in girls, the development of breasts and pubic hair, etc. Bone age: 6. Diagnosis Early diagnosis of scoliosis Early detection and early treatment is the key to prevent the development of severe deformity. Early manifestations of scoliosis include: uneven height of both shoulders, deviation of the spine from the midline, one high and one low scapula, wrinkled skin pattern on one side of the chest, and asymmetry of the back on both sides during forward bending. Early detection relies mainly on parents, school teachers and school nurses. A simple test is the bending test: have the child take off his shirt and stand with his feet on a flat surface in an upright position. The examiner sits in front of or behind the child and looks at the child with his or her eyes level, observing whether the child’s back is equal on both sides. If the bending test is positive, the child should be seen promptly at the hospital. Imaging X-rays: Most important, the cause of scoliosis, its classification, as well as its curvature, location, rotation, bone age, and degree of compensation can usually be distinguished with the help of X-rays. A routine radiograph should include a full-length frontal and lateral view of the spine in the standing position, including the lower cervical spine at the upper end and the lumbosacral joints and iliac wings bilaterally at the lower end. Other special x-rays include supine scoliosis films and traction films to assess the flexibility of scoliosis. CT scan: It can show the bony deformity well, especially the 3D reconstruction CT of the spine can show the congenital vertebral deformity well, and also can do myelography CT scan, which can show the spine and nerve relationship well in some complex spinal deformity, with or without spinal deformity, to guide the surgical treatment. Magnetic resonance imaging (MRI): compared to myelography is a non-invasive test, it has a high soft tissue resolution and can show spinal cord lesions well. Neurological examination Every patient with scoliosis should undergo a detailed and comprehensive neurological examination, noting on the one hand the presence of scoliosis leading to spinal cord compression, causing paraplegia, early tendon reflex hyperactivity and pathological reflexes; on the other hand, the presence of spinal cord abnormalities such as spinal cord bulge, spinal cord longitudinal bifida, and spinal cord cavity. The purpose of scoliosis treatment includes: correcting the deformity; obtaining stability; and maintaining balance. For different types of scoliosis, the principles and methods of treatment vary. The treatment of adolescent-type idiopathic scoliosis is described here. Principles of treatment for adolescent idiopathic scoliosis: If the Cobb angle of scoliosis is less than 25°, it should be closely observed, and if it progresses more than 5° per year and the Cobb angle is greater than 25°, brace treatment should be performed; if the Cobb angle of thoracic scoliosis is between 25° and 40°, brace treatment should be performed; if the scoliosis of the thoracolumbar or lumbar segment is carefully considered; if the Cobb angle is greater than 40° and the brace treatment aggravates >6° per year, surgery should be performed Surgery should be performed for thoracolumbar and lumbar scoliosis >35~. Brace treatment brace treatment emphasizes formal treatment, should be worn at least 20-22 hours a day except for activities such as bathing, follow up once in 3-6 months, and replace the brace every year. If the brace treatment is effective, girls should wear it until 2 years after menarche and Risser’s sign IV°, and boys should wear it until Risser’s sign V° before stopping the brace treatment and continuing to follow up for several years. Surgical treatment is divided into two areas: scoliosis correction and spinal fusion. The orthopedic approach can basically be divided into anterior and posterior orthopedic approaches, sometimes requiring a combination of anterior and posterior surgery. The goal of spinal fusion is to maintain the orthopedic effect and maintain spinal stability. In the surgical treatment of idiopathic scoliosis, the correct choice of orthosis and the extent of fusion is closely related to the outcome of the surgical treatment, as too short a fusion will lead to an increase in compensatory curvature and a more severe deformity. A fusion that is too long will unnecessarily restrict the movement of the spine and greatly affect the physiological function of the spine. In the early 20th century, some new typing methods that are more in line with the three-dimensional characteristics of the spine emerged to guide the selection of orthopedic and fusion ranges, such as the Lenke typing and the H.IMC typing at Peking Union Medical College Hospital in China. 8. Prevention Scoliosis is a common disease that harms adolescents and children. If not detected and treated in time, it can develop into a very serious deformity and can affect cardiopulmonary function and even lead to paralysis in severe cases. School-age children should pay attention to maintaining good sitting and standing posture and strengthening muscle exercise. The key to preventing scoliosis is early detection, early diagnosis, and early treatment, and knowledge of scoliosis prevention and treatment should be promoted in schools and scoliosis screening should be conducted regularly.