Scoliosis is a spinal deformity in which the spine deviates from the body axis in the sagittal plane, but scoliosis is often combined with rotation of the vertebrae, and in fact scoliosis is a deformity of the three-dimensional structure. The more common clinical scoliosis are congenital scoliosis, idiopathic scoliosis, neurofibromatosis combined with scoliosis, neuromuscular diseases combined with scoliosis, such as Marfan’s syndrome, congenital muscular dystrophy and so on.
[Etiology and pathogenesis].
Different types and nature of scoliosis have different causes. The cause of congenital scoliosis is unclear and may be related to abnormalities in the spine during the 5th-8th week of embryonic life. The occurrence of idiopathic scoliosis is currently thought to be primarily related to abnormal secretion of melatonin. Marfan syndrome is a connective tissue disorder in which scoliosis deformity is often present. Neurofibromatosis combined with scoliosis deformity is mainly due to the destruction of vertebral structures by the tumor.
【Diagnosis
(A) Symptoms
The age at which the spinal deformity is detected, the rate of development of the spinal deformity, the accompanying symptoms, such as pain, easy fatigue, shortness of breath after exercise, palpitations, numbness of the lower extremities, difficulty walking, etc., and the presence of secondary sexual characteristics and the time of their appearance.
(B) Physical signs
1, general examination: skin pigmentation, cardiopulmonary function measurement, weighing, height measurement, check the presence of other concurrent deformities.
2, scoliosis examination and assessment
(1) Observe the force line of the trunk with a plumb, check whether the shoulders, trunk, skin pattern, thorax and pelvis are symmetrical, understand the balance of the spine, record the position of the arc and the left and right direction.
(2) Adam bending test: upper limbs flat, both fingers together, elbows extended and bent forward, pay attention to the thoracolumbar augmentation, so as to judge the arc and rotation direction and degree. Special measuring instrument can also be used to check and record.
(3) left and right lateral curvature test of the spine: pay attention to the changes in the line of the spinal spines to observe whether the scoliosis is reduced and the size of the change in scoliosis, so as to understand the flexibility of the spine.
(3) Examination of the nervous system: including sensory and motor functions and reflexes.
(C) laboratory tests
1.X-ray examination
(1) The whole length of the spine (including the cervical vertebrae to the pelvis) of the standing front and side x-ray. Small infants cannot be photographed in the standing position, but only in the lying position, but need to be marked clearly for future comparison. After the infant is able to stand, a standing radiograph should be taken as much as possible. A standing radiograph is a better reflection of the true condition of scoliosis than a lying radiograph.
(2) Measure the curvature of scoliosis. Cobb angles greater than 40° often require instrumentation for correction.
(3) Measurement of vertebral body rotation, commonly used Moe’s method.
(4) Left and right lateral flexion orthopantomographs of the spine to help understand the flexibility of the spine and the fused segments of the spine.
(5) The presence of other concurrent deformities or lesions.
(2) CT examination should be used as a routine examination for scoliosis to understand the conus, the condition of the vertebral plate, the presence or absence of spinal stenosis, the presence or absence of spinal canal separation, and the condition of the spinal cord.
3, MRI examination is more accurate to understand the spinal cord; myelography is feasible when necessary, especially when the X-ray shows vertebral deformity and clinical neurological symptoms.
(D) Differential diagnosis
Idiopathic scoliosis should be distinguished from scoliosis of neuromuscular origin. In the latter case, there are lesions of the spinal cord, peripheral nerves or/and muscles.
Treatment
First, older children with scoliosis – using a phase of surgery or staged surgery orthopedic
1. Phase I surgery: anterior spinal release and fusion, including discectomy, hemivertebral resection, bone bridge resection, fusion rib resection, etc., and implantation of autologous or allogeneic bone in the intervertebral disc space. About a week after the release surgery, spinal traction is performed for 2~3 weeks, commonly used methods include bilateral lower limb distal femoral traction and occipito-mandibular confrontation horizontal traction, cranial ring – gravity vertical traction.
2, the second phase of surgery: device placement orthopedics and spinal fusion. At present, the main choice of C-D spinal device placement.
3, postoperative treatment.
(1) Observe the child’s bipedal toe activity at all times to understand the function of the spinal cord.
(2) Fasting for about 24 hours can be eaten, and gradually transition from a liquid diet to a normal diet. Children with gastrointestinal reactions and malnutrition can be given incomplete intravenous nutrition.
(3) Every 4~6 hours, alternate left and right lying position to avoid pressure on the wound and skin decubitus ulcers.
(4) Routine intravenous antibiotics for 5~7 days postoperatively to prevent infection.
(5) Look at the wound 3 days after surgery and change the dressing. 2 weeks to remove the stitches, the use of intradermal suture can be exempted from the removal of stitches, and has a cosmetic effect.
(6) 5~7 days postoperative review of the ortho-lateral spine to understand the orthopedic effect of surgery and the position of implanted devices.
(7) After 3 months of bed rest, gradually start to move to the ground, and wear a support undershirt when moving to the ground.
(8) Avoid strenuous exercise on weekdays to prevent impact on the spine.
4.Follow-up: Take a front and side X-ray of the spine every 6 months to 1 year to observe the maintenance of the orthopedic effect of the spine and the position of the implanted devices.
Second, infantile scoliosis – according to the spinal deformity, choose hemivertebrectomy, in situ fusion, anterior-posterior fusion, internal fixation of instruments, thoracoplasty, and subcutaneous growth rods and other orthopedic procedures.
Third, the treatment of neurofibromatosis combined with scoliosis
1, non-dystrophic treatment is basically the same as idiopathic scoliosis, but the indications for surgery are Cobb’s angle 30 °.
2, dystrophic type is appropriate to perform anterior and posterior spinal implant fusion to enhance the stability of the spine. Anterior spinal fusion can be performed with direct transfer graft of rib with vascular tip.
3, in order to prevent the recurrence of scoliosis or aggravation of the original arc after surgery, the scope of fixation of the operation should be 2~3 vertebrae each above and below the scoliosis range shown by X-ray.
4, spinal fusion postoperative bone graft block pseudo-joint prevention: intraoperative fusion range of soft tissue and periosteum on the vertebral plate should be stripped clean, increase the amount of bone graft, using autologous bone, allogeneic bone, artificial bone, or add bone formation protein bone graft method, postoperative can also add Chinese medicine to promote the formation of bone scabs.
5.The excision of local neurofibroma should be as thorough as possible and minimize the damage to normal tissues.
6, neurofibroma complicating scoliosis can only be treated surgically, so early surgery should be performed to prevent the deterioration of neurological complications and deformities.
Fourth, congenital scoliosis combined with spinal longitudinal bifida treatment
Congenital scoliosis is sometimes combined with longitudinal spinal bifida or/and spinal cord tethering syndrome, which requires surgical excision or/and tethering release due to its effect on the spinal cord. The spinal ridge resection for longitudinal spinal bifida and the release of the spinal cord tethering can be performed prior to orthopedics or at the same time as the posterior spinal instrumentation placement orthopedics.
[Complications and management].
The most serious complication of scoliosis correction surgery is acute spinal cord dysfunction, which can occur during and after surgery.
Once acute spinal cord dysfunction occurs, the internal spinal fixation device should be removed immediately, and then the cause should be analyzed and investigated.
Prevention
1. Before surgery, a full understanding of the spinal deformity and the combined spinal cord abnormalities should be obtained. Commonly used tests include 3D CT spine imaging, MRI, or myelography.
2. Intraoperative monitoring of spinal cord function is performed throughout the surgery, with sensory evoked potentials and motor evoked potentials, and the best combination of both. Combined with intraoperative arousal test.
Postoperatively, the sensory and activity changes of bilateral lower limbs and feet should be closely monitored.