Early diagnosis is very important to enable early treatment. Therefore, the screening of primary and secondary school students needs to be sound and prevention-oriented.
(I) Medical history
A detailed history is taken of everything related to spinal deformity, such as the patient’s health status, age and sexual maturity. Past history, surgical history and history of trauma should also be noted. Young children with spinal deformities should be informed about the health status of their mothers during pregnancy, any history of medication during the first trimester, and any complications during pregnancy and delivery. Family history should be noted for spinal deformities in other individuals. Family history is particularly important in neuromuscular spinal cases of kyphosis.
(ii) Physical examination
Three important aspects are noted: deformity, etiology and complications.
1. Full exposure, wearing only shorts and loose outerwear with an opening in the back, noting pigmented skin lesions, the presence of coffee spots and subcutaneous tissue masses, and the presence of hair and cystic material on the back. Note the breast development, symmetry of the chest, the presence of funnel chest, chicken chest and rib bulge and surgical scars. The examiner should look carefully from the front, side and back.
The patient then faces the examiner and bends forward to observe whether the back is symmetrical: a bulge on one side indicates a rotational deformity of the rib canal and vertebrae. Then the examiner observes from the back of the patient to see if the lumbar region is symmetrical and to check if the lumbar vertebrae are rotational deformities. Also note whether the two shoulders are symmetrical, and also measure the distance between the quarter rib angle and the hip bone question on both sides, and also put a lead hammer line from the cervical 7 spinous process, and then measure the distance from the hip crack to the vertical line to indicate the degree of deformity.
Then the range of motion of spinal flexion, hyperextension and lateral bending is checked. The bendability of each joint is examined, such as wrist and thumb proximity, finger hyperextension, and knee and elbow retroflexion.
Finally, a careful neurological examination should be performed, especially of both lower extremities. Corneas should be noted in those suspected of having mucopolysaccharidosis. The palate should be noted in those with Marfan’s syndrome.
The patient’s height, weight, bilateral arm spacing, length of both lower extremities, and sensation should be recorded.
(iii) X-ray examination
1, upright full spine frontal and lateral images. X-rays must emphasize the upright position, not the prone position. If the patient cannot stand upright, it is appropriate to use a seated image so as to reflect the true picture of scoliosis. This is the most basic means of diagnosis.
X-rays need to include the entire spine.
2. Left and right bending and traction in the supine position. Cobb’s angle is greater than 90 degrees or neuromuscular scoliosis, as there is no proper muscle correction of scoliosis, traction images are often used to check its flexibility to estimate the degree of correction of scoliosis and the length required for fusion of each column. The softness of the kyphosis requires the taking of lateral images in the hyperextension position.
3. Oblique image. To examine the fusion of the spine, oblique images of the lumbosacral region are used for patients with spondylolisthesis and isthmus bifida.
4.Ferguson image. To examine the lumbosacral joint junction, in order to eliminate anterior lumbar convexity, the bulbous canal is tilted 30 degrees to the cephalad side in male patients and 35 degrees in female patients, so that a true orthostatic lumbosacral image is obtained.
5. Stagnara image. In patients with severe scoliosis (>100 degrees), especially with kyphosis and vertebral rotation, it is difficult to visualize the deformity of the ribs, transverse processes and vertebral bodies on ordinary X-rays. Rotation images need to be taken to obtain a true anterior-posterior image. The patient is rotated under fluoroscopy and the film is taken when the maximum curvature appears, with the cassette parallel to the medial side of the rib augmentation and the bulb perpendicular to the cassette.
6.Tomographic image. To examine congenital deformities with unclear lesions, fusion of implant blocks and some special lesions such as osteoid osteoma.
7.Cut image. The patient is bent forward and the bulbous canal is tangential to the back. It is mainly used to examine the rib cage.
8.Myelography. Not routinely used. Indications are spinal cord compression, spinal cord masses, suspected lesions in the dural sac X-images see widening of the distance between the vertebral arches, incomplete closure of the spinal canal, spinal cord longitudinal fracture, spinal cord cavernous disease. Myelography is needed to understand spinal cord compression, as well as for planned hemivertebral body resection or proposed hemivertebral body wedge resection.
CT and MRI are helpful for patients with combined spinal cord lesions. Such as spinal longitudinal fracture, spinal cavernous disease, etc. It is important to understand the plane and extent of the bony crest for surgical orthopedics, removal of the bony crest and prevention of paraplegia. However, it is expensive and should not be used for routine examination.
10, the main points of X-ray reading
End vertebrae: the most cephalad and caudal vertebrae in the bend of scoliosis.
Top vertebra: the most severe deformity in the bend, the vertebra that deviates farthest from the vertical line.
Primary scoliosis, i.e., primary scoliosis: it is the earliest bend to appear and the largest structural bend with poor flexibility and correctability.
Secondary scoliosis: compensatory scoliosis or secondary scoliosis, is the smallest bend, more flexible than the primary scoliosis, and can be structural or nonstructural. It is located above or below the primary scoliosis and serves to maintain the normal line of force in the body, and the vertebrae are usually not rotated. When there are three bends, the middle bend is often the main lateral bend, Fang has four bends, the middle two for the double main lateral bend.
11, the measurement of curvature and rotation
Curvature measurement: (1) Cobb’s method: the most commonly used, the head side of the upper edge of the terminal vertebrae of the vertical line and the tail side of the lower edge of the terminal vertebrae of the intersection angle that is Cobb’s angle. If the upper and lower edges of the terminal vertebrae are not clear, the line of the upper and lower edges of the vertebral arch can be taken, and then the angle of intersection of their vertical lines is the Cobb’s angle. (2) Ferguson method: rarely used, sometimes used to measure mild scoliosis. Find the midpoint of the terminal vertebra and the parietal vertebra, and then draw two lines from the midpoint of the parietal vertebra to the midpoint of the upper and lower terminal vertebra, respectively, and the angle of intersection is the angle of lateral bending.
Determination of vertebral body rotation.
Nash and Mod divided it into 5 degrees according to the position of the vertebral arch root on the orthogonal x-ray. 0 degree: the arch root is symmetrical; I degree: the convex side of the arch root moves to the midline, but does not go beyond the first frame, and the concave side of the arch root becomes smaller; II degree: the convex side of the arch root has moved to the second frame, and the concave side of the arch root disappears; III degree: the convex side of the arch root moves to the center, and the concave side of the arch root disappears; IV degree: the convex side of the arch root crosses the center and is close to the concave side.