Scoliosis, also known as scoliosis, is a three-dimensional deformity of the spine that includes serial abnormalities in the coronal, sagittal and axial positions. In a normal person, the 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.
Etiology
Scoliosis can be classified as functional or organic, or non-structural and structural, according to the etiology.
I. Non-structural scoliosis
Non-structural scoliosis refers to temporary scoliosis caused by certain causes, which can return to normal once the cause is removed, but can also develop into structural scoliosis if it exists for a long time. Generally, this kind of patient’s scoliosis often disappears on its own when lying down, and the spinal structures are normal when X-rays are taken.
1. postural scoliosis.
2, low back and leg pain, such as disc herniation and tumors.
3, caused by unequal length of both lower limbs.
4, caused by contracture of the hip joint.
5, inflammatory stimulation (such as appendicitis).
6, hysterical scoliosis.
Second, structural scoliosis
Structural scoliosis is relative to non-structural scoliosis and can be divided into the following categories.
1, idiopathic
The most common, accounting for 75%-85% of the total, the cause of the onset is not clear, so it is called idiopathic scoliosis. Depending on the age of onset, it can be divided into three categories.
(1) Infant type (0 to 3 years old) ① natural healing type; ② progressive type.
(2) Juvenile type (4 to 10 years old)
(3) Juvenile type (>10 years old to skeletal maturity).
Among the above three types, the adolescent type is the most common.
2.Congenital
(1) Malformation type
(1) congenital hemivertebral body.
② congenital cuneiform vertebrae.
(2) poorly segmented type.
(3) mixed type, combined with the above two types.
3.Neuromuscular
It can be divided into neurogenic and myogenic, and is a scoliosis caused by neurological or muscular disorders resulting in muscle imbalance, especially asymmetry between the left and right paraspinal muscles. Common causes include post-polio, cerebral palsy, spinal cord cavitation, and progressive myasthenia gravis.
4. Neurofibromatosis combined with scoliosis.
5, scoliosis due to interstitial lesions
Such as Marfan syndrome, congenital polyarticular contracture, etc.
6. Acquired scoliosis
Such as scoliosis caused by ankylosing spondylitis, spinal fracture, spinal tuberculosis, septic chest and thoracic surgery such as thoracoplasty.
7.Other causes
Such as scoliosis caused by metabolic, nutritional or endocrine causes.
Diagnosis
I. Early diagnosis of scoliosis
Early detection and 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 bilateral back asymmetry 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 promptly seen at the hospital.
Second, imaging examination
(1) X-ray examination: the most important. Generally, the cause of scoliosis, classification, as well as curvature, location, rotation, bone age, and degree of compensation can be distinguished with the help of X-ray films.
Routine radiographs 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 views, traction views, etc., which can assess the flexibility of scoliosis.
(2) CT scan: It can well show the bony deformity, especially the 3D reconstruction CT of the spine can well show the congenital vertebral deformity, and can also do myelography CT scan, which in some complex spinal deformity can well show the relationship between the spine and the nerve, with or without spinal deformity, to guide the surgical treatment.
(3) MRI: Compared with myelography, which is a non-invasive examination, it has a high soft tissue resolution and can show spinal cord lesions well.
III. Neurological examination
Each patient with scoliosis should undergo a detailed and comprehensive neurological examination, noting on the one hand whether there is scoliosis leading to spinal cord compression, causing paraplegia, early tendon reflex hyperactivity and pathological reflexes; on the other hand, whether there is a combination of spinal cord abnormalities such as spinal cord bulge, spinal cord longitudinal bifida, spinal cord cavity, etc.
Treatment
The treatment of scoliosis can be divided into two main categories, namely non-surgical treatment and surgical treatment.
I. The general treatment principles are as follows.
1. Generally, idiopathic scoliosis within 20 degrees can be left untreated for the first time and closely observed, and if it worsens more than 5 degrees per year, it should be treated with bracing.
2, the first diagnosis of 30 degrees to 40 degrees of adolescent idiopathic scoliosis, should be immediately brace treatment, because more than 60% of this group of patients will develop aggravation.
3, adolescent idiopathic scoliosis needs to be considered for surgical treatment in the following cases.
(1) Those with thoracic curvature greater than 40 degrees and thoracolumbar curvature/low back curvature greater than 35 degrees.
(2) Those whose scoliosis is not controlled by brace treatment and is rapidly progressing
(3) Those with significant low back pain or nerve compression symptoms.
II. Non-surgical treatment
Common non-surgical treatment methods include physiotherapy, gymnastic therapy, plaster, brace, etc., but the main and most reliable method is brace treatment. The principles of brace treatment are as follows.
1. Indications for brace treatment.
(1) mild scoliosis between 20 and 40 degrees, scoliosis more than 40 degrees is not suitable for brace treatment.
(2) Children with immature bones should be treated with braces.
(3) Two structural curvatures of 50 degrees or a single curvature of more than 45 degrees are not suitable for brace treatment
(4) Scoliosis with combined thoracic convexity should not be treated with bracing.
(5) Scoliosis of the lumbar segment or thoracolumbar segment with long segmental curvature and good flexibility below 40 degrees is treated well with bracing.
Patients and parents who do not cooperate should not be treated with bracing.
The most common method of evaluating the maturity of scoliosis is to observe the movement of the epiphysis of the iliac crest (Risser’s sign). The epiphyseal movement of 25% is degree I and 50% is degree II and 75% is degree III. The movement to the posterior superior iliac spine is degree IV and the fusion of the epiphysis with the iliac spine is degree V. Risser’s degree V indicates the end of spinal growth and development.
2.Support wear
When the brace is started, 23 hours per day are required, one hour for physical therapy, breathing exercises, etc. If the cooperation of the patient and family cannot be obtained, the brace should be worn for at least 16 hours a day. If the Cobb angle can be reduced by 50% after wearing the brace, a better treatment effect can be expected. After one year of treatment, if the scoliosis can be reduced by 50%, the wearing time can be gradually reduced and, with the increase of Risser, the brace can be worn only at night. If the scoliosis starts to increase by more than 5 degrees again, the wearing time needs to be increased again. Factors that influence the progression of scoliosis include the type of scoliosis, age, time of menarche and Risser’s sign.
III. Surgical treatment
In patients with congenital scoliosis, if the scoliosis is the type that progresses easily or if the scoliosis progresses significantly during the observation period, surgery should be performed as early as possible, and generally 3 to 5 years of age is a better time for surgery. Because of the complex etiology and many types of scoliosis, the need for surgery is never simply based on the patient’s age or the degree of scoliosis, but should also take into account the type of deformity, characteristics, segments, rate of progression, the patient’s bone age development and the degree of impact of the deformity on the patient’s posture.
There is a consensus that progressive congenital scoliosis should be operated early because it is difficult to correct because not only does the deformity increase with age, but it also becomes rigid. However, idiopathic scoliosis that undergoes premature posterior correction and fusion in childhood may affect its spinal growth and development, and it is likely that the deformity will worsen in the long term. In addition, factors such as the balance of the spine and the effect of surgery on the growth and mobility of the spine should be taken into account. Therefore each patient with scoliosis should be analyzed specifically and individualized treatment measures should be taken.
The goals of scoliosis surgery are to.
Prevent progression of the deformity; restore spinal balance; correct as much of the deformity as possible; preserve as many mobile segments of the spine as possible; and prevent nerve damage. With current three-dimensional orthopedic techniques and pedicle screw fixation, scoliosis can be surgically corrected well, but not 100%, because the surgery also takes into account the tolerance of the patient’s spine and spinal cord, and overcorrection can easily lead to failure of the internal fixation, increase the incidence of surgical complications, and even lead to neurological damage and paralysis. The degree of correction of scoliosis varies by age, degree and etiology, and the correction rate of idiopathic scoliosis usually reaches 60% to 80%.
Prevention
Scoliosis is a common disease that affects 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 exercises. 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.
Scoliosis terminology
Cobb angle: the end vertebrae are most heavily tilted in the entire bend, a straight line is drawn along each of the upper endplate of the upper end vertebrae and the lower endplate of the lower end vertebrae, and the angle of intersection of the two lines of perpendicularity
Risser’s classification: ossification gradually moves from the anterior superior iliac crest to the posterior superior iliac crest, dividing the iliac crest into four equal parts, the epiphysis moves 25% for grade I; 50% for grade II, 75% for grade III, moves to the posterior superior iliac crest for grade IV, and the epiphysis fuses with the iliac bone for grade V. This marks the cessation of the development of the bone-iliac system.
The finer principles of treatment are observation as well as bracing and surgical treatment.
① Those with a Cobb angle less than 25° should be closely monitored, and if the progression is >5° per year and the Cobb angle is >25°, bracing should be performed.
② Scoliosis with a Cobb angle between 25° and 40° should be treated with bracing, and surgery is recommended if the annual progression is >5° and the Cobb angle is >40°.
③ Scoliosis with a Cobb angle of 40° to 50°: Since scoliosis with a curvature greater than 40° has a greater chance of progression, surgery should be recommended if the patient is developmentally immature. For developmentally mature patients, surgery should also be performed if the scoliosis develops a curvature greater than 50° and follow-up reveals a significant progression of the scoliosis.
④ Cobb angle greater than 50°: surgical treatment is undertaken.