Disease Introduction:
Guidelines for the Treatment of Scoliosis
Scoliosis, also known as scoliosis, is a pathological condition in which one or several segments of the spine become laterally curved and gradually worsen. It can not only affect the spine, chest, ribs, and pelvis, but in severe cases, it can also affect cardiovascular function and even the spinal cord, causing paraplegia. Severe scoliosis requires surgical correction, while mild scoliosis can be prevented or reduced from developing deformities through guided physical therapy, electrical stimulation therapy, traction therapy, especially brace therapy.
classification
Spinal deformities can be classified into cervical, thoracic, and lumbar deformities based on their location. According to morphology, it can be divided into anterior convexity, lateral convexity, and posterior convexity deformities. According to the causes of spinal deformities, they can be classified into idiopathic, congenital, neuromuscular, interstitial, traumatic, and other causes. For scoliosis, idiopathic is a common cause
Coronary malformation is divided into upper thoracic segment, middle thoracic segment, and thoracolumbar segment/lumbar segment.
In terms of clinical manifestations, scoliosis can cause back protrusion deformity, "razor back" deformity, and even "funnel chest" or "chicken chest" deformity. At the same time, the combination of these back deformities can be accompanied by bilateral shoulder joint imbalance or pelvic imbalance, as well as unequal length of the lower limbs, which can cause obvious local deformities in patients, reduce height, decrease the volume of the chest and abdominal cavity, and even cause damage to neurological function, respiratory function, digestive function, etc. At the same time, for patients with underdeveloped spinal bone structure itself, it can be accompanied by neurological developmental abnormalities such as meningeal protrusion and invisible spina bifida. In addition, congenital scoliosis may also be accompanied by cardiovascular system abnormalities, tracheoesophageal fistula, polycystic kidney disease and other organ abnormalities
Idiopathic scoliosis
pathogeny
Idiopathic scoliosis, from an etiological perspective, is not very clear, but it is related to genes and genetics to some extent. In addition, there is also an imbalance in the distribution of paraspinal muscles themselves. Morphology refers to the absence of structural abnormalities in the vertebral body itself, normal vertebral separation, symmetrical pedicle, and well-developed vertebral lamina and articular processes.
classification
According to the time of onset, it can be classified into four types: infants and young children, adolescents, teenagers, and adults. Infants and young children refer to those who develop the disease between the ages of 0-3, while adolescents refer to those who develop the disease between the ages of 4-10, usually before puberty; The age of onset for adolescent scoliosis is 10 years old - the stage of epiphyseal closure, which is the most common type of scoliosis before adulthood,; Adult idiopathic scoliosis refers to scoliosis that develops during adolescence and progresses further into adulthood due to untreated or partially treated deformities without significant improvement
clinical manifestation
Idiopathic scoliosis is most commonly known as "razor back", and some patients may also experience bilateral shoulder joint imbalance and pelvic imbalance. Usually, neurological damage is rare. It is worth noting that some neurofibromatosis or congenital scoliosis may have a curvature similar to "idiopathic scoliosis", and a clear evaluation of spinal cord function must be conducted before surgery.
Congenital scoliosis
For congenital scoliosis or kyphosis, it usually refers to spinal deformities caused by structural abnormalities in the vertebral body itself. Its pathological structural types are usually divided into vertebral bone defect of formation or defect of segmentation.
The biggest characteristic of incomplete vertebral body formation is that the intervertebral space usually exists normally, but the pedicle on one side of the vertebral body is underdeveloped or disappears, or merges with adjacent vertebral bodies, or X-ray shows an increase in the distance between the vertebral bodies and the intervertebral space; The biggest characteristic of incomplete vertebral separation is the disappearance of the intervertebral space between two vertebrae (or even multiple vertebrae), the fusion of vertebrae into a whole, and the disappearance of one side of the pedicle, even forming a bony connection (bonebar), while the opposite side may have the formation of a semi vertebral body accompanied by intervertebral disc development. This situation can occur in the coronal or sagittal plane, resulting in scoliosis or kyphosis.
Congenital spinal deformities are usually accompanied by spinal cord deformities, such as intraspinal tumors, spinal cord diastasis (5-21%), formation of bony (membranous) mediastinum in the spinal canal, tethered spinal cord, low cone, spinal cord cavity, meningeal protrusion, etc. At the same time, benign tumors such as epidermoid cysts, dermoid cysts, teratomas, etc. may also occur in the spinal canal. The reason for the accompanying occurrence of such spinal cord and spinal deformities is due to abnormal development of the spinal cord and spinal nodes formed during embryonic development (6 weeks before embryonic development). In clinical manifestations, it can manifest as the lumbar sacral sinus tract, increased hair, local elevation, subcutaneous lipoma, etc
Congenital spinal deformities are usually accompanied by developmental abnormalities of other organs, which can be abbreviated as VACTERL, namely V-vertebral dysplasia, A-anal atresia, C-cardiovascular malformation, TE tracheoesophageal fistula, R-renal dysplasia, and L-limb dysplasia. At the same time, it may also be accompanied by lesions such as Sprengel Deformity and Klippel Feil syndrome.
For the treatment of congenital scoliosis, it is divided into observation and surgical treatment. Brace therapy is not effective for this type of patient because the corrective force of braces cannot correct congenital deformities in the vertebral body. If the patient has no obvious appearance abnormalities, such as shoulder and hip asymmetry, back deformities, and no discomfort, they can consider continuing observation for about 4-6 months; On the contrary, surgical treatment can be considered. Depending on age, deformity location, and overall balance, different surgical methods can be chosen. Such as hemivertebral epiphyseal fusion, hemivertebral resection, and in situ fusion of scoliosis and convexity. At present, with the improvement of surgical instruments and concepts, the treatment of congenital hemivertebrae mainly considers the removal of hemivertebrae, internal fixation, orthopedic fusion and surgery. Congenital scoliosis can cause the progression of deformities at any age.
Neuromuscular scoliosis
Definition and classification of neuromuscular scoliosis, mainly caused by systemic muscle system disorders, resulting in muscle weakness in the chest and back, and the inability of paraspinal muscles to support the spine well. The Scoliosis Research Society (SRS) categorizes it into upper motor neuron damage (such as cerebral palsy, syringomyelia, spinal cord injury) and lower motor neuron damage (such as polio, spinal muscle atrophy, etc.).
clinical manifestation
The most common cause of cerebral palsy is cerebral palsy, which is mostly caused by neurological developmental disorders due to hypoxia in newborns, leading to sustained muscle atrophy and developmental imbalance. At the same time, this type of child is different from other types of scoliosis, often accompanied by systemic diseases such as joint dislocation, epilepsy, Chilean disorders, and even bedsores. The onset of the disease usually begins in infancy or adolescence, with well-developed spinal bones and no variation in vertebral body shape. However, due to the inability to walk in both lower limbs, most children can only be confined to wheelchairs, accompanied by significant muscle atrophy in both lower limbs. The hip joint is prone to inward contraction on one side and outward dislocation on the other side. Meanwhile, this muscle atrophy can further affect the intercostal muscles that support respiratory function (such as Duchenne syndrome), leading to early death
The characteristics of spinal deformities are usually characterized by a clear "C" - shaped curvature of the spine, which continuously changes from cervical to thoracic to lumbar vertebrae, without obvious compensatory scoliosis formation. The lateral curvature is large, affecting the segments frequently, and the spinal flexibility is poor, often accompanied by obvious pelvic tilt.
The treatment principle is to evaluate the overall condition, orthopedic specialty, and spinal deformity at the same time. For such patients, a seat with supporting function is very necessary. Support therapy is basically ineffective after the peak of adolescent growth. Surgical fixation usually requires fusion from the upper thoracic spine (T1 or T2) to the pelvis.
Neurofibromatosis is an important cause of spinal lateral (posterior) convexity. Neurofibromatosis itself is caused by genetic defects leading to abnormal development of neural crest cells, resulting in multi system damage. According to clinical manifestations and genetic localization, it is divided into neurofibromatosis type I (NFI) and type II (NFII)
When NFI patients undergo physical examination, milk coffee spots (Caf é au lait) and peripheral nerve neurofibromas can usually be seen on the skin surface, mostly located in non exposed areas of the trunk. In addition, Lisch nodules can be seen in the eyes, which are fibrous tumors or plexiform neurofibromas of the upper eyelid. The orbit can be palpated with masses or protruding eye pulsations. Slit lights can show small orange yellow circular nodules of iris millet, which are characteristic of NFI and can increase with age. The diagnostic criteria are at least 6 before puberty, with a diameter greater than 5mm (after puberty, the diameter is greater than 15mm), and have high diagnostic value; Freckles on the whole body and armpits are also one of the characteristics; Discovery of 2 or more neurofibromas or plexiform neurofibromas; And there are NFI patients among relatives; Two or more Lisch nodules; Bone damage. The location of genetic lesions is mostly located at 17q11. 2.
NFII patients are mostly central nervous system neurofibromatosis or bilateral acoustic neuroma disease. The diagnostic criteria are that first-degree relatives have NFII accompanied by one side of the acoustic neuroma, or two types of neurofibroma, meningioma, glioma, and Schwann cell tumor, with genetic lesions located in 22q.
Neurofibromatosis type I can easily lead to spinal lateral (posterior) convexity deformity, with early onset (usually before puberty), rapid progression of lateral (posterior) convexity, obvious deformity, stiff curvature, and decreased bone strength. Brace therapy has almost no effect on correcting deformities
For the treatment principles of neurofibromatosis type I, patients should be divided into two groups: those without developmental malnutrition and those with developmental malnutrition. The former has a spinal curvature similar to idiopathic scoliosis, and the treatment principles, such as fusion and segmental differentiation, are also similar. But in terms of actual angle and bone quality, the two are significantly different. Neurofibromatosis progresses significantly in curvature, and postoperative pseudarthrosis is more common, with visible defects in vertebral development. For the group without developmental malnutrition below 35 ° C, experimental brace treatment is feasible; From 35 ° to 45 °, simple posterior surgical treatment is feasible; A combination of anterior and posterior surgery is feasible above 60 ° to increase fusion rate. The group with developmental malnutrition usually exhibits "shell like" changes in the vertebral body, severe rotation of the vertebral body, increased distance from the pedicle, and "pencil" sign in the protruding ribs, which are related to tumors in the spinal canal and widening of the dura mater. The progression of curvature often occurs before the age of 7. The brace treatment is completely ineffective. from
Due to the large curvature and underdeveloped vertebral body, surgical treatment usually cannot provide sufficient strength to control the progression of deformities, and is prone to the formation of local pseudarthrosis and postoperative curvature progression. There is no significant difference in the incidence of pseudarthrosis between malnutrition and non malnutrition, but 360 ° fusion can improve the fusion rate, especially for patients with lateral kyphosis, to avoid the progression of deformities. Compared to other types of scoliosis, neurofibromatosis is more prone to early correction and fusion, and has little impact on trunk growth.
Marfan syndrome, also known as the cause of scoliosis, has a similar male to female incidence rate and is a chromosomal dominant inherited disease (caused by a 15q21.1 mutation on chromosome 15). However, about 25% of patients are also caused by chromosomal mutations. Marfan syndrome is also known as spider paw deformity. The onset age of spinal deformities is early, with 50% of patients experiencing them at the age of 6. Although the appearance resembles idiopathic scoliosis, the Cobb angle is large, progresses rapidly, and the curvature is rigid, making it difficult to correct. At the same time, lateral displacement between vertebral bodies is prone to occur, and bone grafting is prone to non healing.
Marfan's comprehensive diagnosis:
For specific cases: if there is no family or genetic history, at least two main criteria of different systems and another organ involvement are required; If a known Marfan gene mutation is detected, a diagnosis can be made if there is a primary criterion and a secondary system involved in a system; Patients with a family history can be diagnosed by having a primary criterion of one system and involvement of a second system.
adult Scoliosis
There are two main pathological types of adult scoliosis. One is due to the progression of idiopathic scoliosis from adolescence to adulthood, resulting in corresponding symptoms, known as adult idiopathic scoliosis; The second is due to intervertebral disc degeneration during adulthood, known as degenerative adult scoliosis (Denovo Scoliosis). The latter is the most common type. In addition, it also includes adult manifestations of congenital scoliosis, paralytic scoliosis, and post-traumatic deformities.
The incidence of adult scoliosis can reach 2.9%.
The main clinical manifestation is pain, accompanied by symptoms of lumbar spinal stenosis. When inquiring about the medical history, it should include an evaluation of daily functions and the impact of spinal deformities on work and life. Physical examination includes examination of spinal deformities, musculoskeletal system, and nervous system, as well as the length of both lower limbs, to avoid exacerbating the body's imbalance after correction.
Imaging examinations include full spine anteroposterior and lateral views, as well as dynamic views (left and right bending images) to clarify disc activity. The difference in imaging between adult idiopathic scoliosis and adult degenerative scoliosis is that: 1. The former usually has two curvatures, while the latter usually has only one; 2. The former has good compensation for the trunk and pelvis, while the latter often experiences decompensation; 3. The former has no significant degeneration of the intervertebral space, and the intervertebral space is of equal height without obvious sagittal or coronal slip; The latter has severe intervertebral space degeneration, uneven height on both sides, obvious slippage, and changes in endplate proliferation; CT clearly shows changes in bone structure, especially in patients with severe osteoporosis; MRI is used to clarify the condition of intervertebral disc degeneration and nerve compression, and some scholars even use discography to determine the level of distal fusion and intervertebral disc.
Due to the particularity of its patient population, the incidence of surgical complications can reach 40%. Preoperative evaluation of the patient's overall condition (including cardiovascular and cerebrovascular function, lung function, etc.) is required. To learn more about medical knowledge about scoliosis, please click on the link:/2013/0523/133607.html
The treatment process for scoliosis
The treatment of scoliosis can be divided into two categories, namely non-surgical treatment and surgical treatment. In early cases, non-surgical treatment is often used, including gymnastics therapy, electrical stimulation therapy, traction therapy, plaster correction therapy, and brace treatment. However, scoliosis develops rapidly during puberty, and idiopathic scoliosis with a Cobb angle of over 40 ° or rigid congenital scoliosis that is ineffective with non-surgical treatment should be treated with early surgical treatment. The key points of non-surgical treatment and commonly used surgical treatment are as follows: Non surgical treatment:
Treatment methods and treatment guidelines
matters needing attention
Gymnastics therapy can achieve good therapeutic effects, while
1. Crawling forward and backward 2. Left and right leaning seats 3. Touching the top of the head
Significant structural changes and congenital scoliosis are difficult to separate
Corrective gymnastics therapy wall 4. Extend both arms horizontally 5. Sit ups 6. Lower limbs
Through corrective gymnastics and orthotics, it is necessary to combine it with other non-surgical treatments
method
Extend 7 backwards. Raise your legs 8, take a deep breath and exhale slowly 9. quite
Therapy, especially the combination of brace therapy and application, therefore, the body
Pull up and stand up. Specific learning is required based on the operation diagram.
Exercise therapy is still a necessary auxiliary therapy.
At present, the commonly used electrical stimulation is dual channel surface electrical stimulation
Stimulator, two sets of electrodes are placed on the convex side of the side bend. 1. Positioning. 2. Determination of effective intensity of electrical stimulation
Rectangular electrical stimulation therapy with alternating output of two channels at specific locations on the body surface must have sufficient intensity to achieve the therapeutic goal
The electric shock wave induces alternating contractions of two groups of paraspinal muscles and estimates the intensity of electrical stimulation through the following method.
Zhang provides sustained corrective force to the scoliosis of the spine,
In order to achieve the goal of preventing the aggravation of scoliosis
1. CTLSO fixation range includes cervical, thoracic, and lumbar vertebrae
Support therapy
Vertebral and sacral vertebrae. 2. The fixed range of TLSO includes the use of braces therapy for idiopathic puberty and adolescence
Lower thoracic, lumbar, and sacral vertebrae. 3. When wearing braces, there may be scoliosis, which can affect congenital scoliosis or bone maturation
The wearing time of braces should not be less than 23 hours per day. If the treatment of scoliosis braces is ineffective, they are often used to treat the spine
There are two main types of braces for treating scoliosis: CTLSO and TLSO.
The treatment needs to be persistent, and if there are no contraindications, the use of braces should be continued until
Mature bone growth and development
Traction therapy can prevent or slow down the progression of scoliosis
Traction therapy
Step aggravation or improvement of scoliosis to a certain extent, 1. Head pelvic ring traction: (1) Head ring installation
Traction therapy, currently more important, is used for spinal (2) pelvic ring installation 2, scoliosis anti suspension
Preoperative preparation for scoliosis to achieve maximum traction during surgery.
Ground correction to prevent one-time stretching during surgery, avoiding or
Surgical treatment:
Reduce the occurrence of complications from spinal cord nerve injury.
common method
matters needing attention
Surgical indications
Currently, Harrington has idiopathic scoliosis, which develops rapidly during puberty and has a Cobb angle greater than 40 °
Orthopedics with open instruments is often associated with surgical treatment for congenital scoliosis, especially for stiff or neuromuscular types
Patients with Luque segmental scoliosis leading to spinal collapse should undergo early surgery, as the longer the course of the disease, the more severe the development
The combination of lower wire fixation should be corrected more difficult. 2. Age: Generally, orthopedic fixation and fusion surgery with instruments should be performed after the age of 12
To reduce the need for simple implementation and prevent local fusion due to worsening of congenital scoliosis, early intervention is necessary
Harrington surgery. 3. The degree of scoliosis is generally defined as above a Cobb angle of 40 ° both domestically and internationally
Surgical treatment will be performed for cases of detachment or breakage of the stick, while non-surgical treatment will be performed for cases below 40 °. 4. Rotation of the scoliosis area will be performed
Symptoms
Severe thoracic scoliosis accompanied by obvious chest deformities or hunchback (large hump angle) deformities
Luque surgery should be performed earlier than lumbar scoliosis surgery to prevent worsening of respiratory function. 5.
Patients with postoperative pseudarthrosis and early paraplegia should undergo early surgery to reduce pressure and relieve paraplegic factors,
Luque has a low surgical rate, but each wire is used to correct and prevent further deformity aggravation. 6. For older adults with scoliosis,
If passing through the epidural space increases lumbar back pain or spinal instability caused by vertebral hyperplasia in the deformed area, it may also be considered
Opportunities for spinal cord injury and fixed fusion surgery.
Reduced Luque vertebrae
The complex threading of steel wire under the Harri Luque board
The rigidity of the spinous process basal bone buckle avoids or reduces straightness
Silk fixation method
Injury to spinal cord nerves
Opportunities
Dwyer surgery
This method is satisfactory for orthodontic treatment, but there are many complications.
Fixed segments are few, which affects deformities
The segment only applies pressure, not
The Zielke surgery has a supportive effect, thus affecting the gods
Opportunity for injury caused by pulling
Less
Mainly suitable for adolescence
Idiopathic scoliosis
It is currently a posterior spinal correction
C. D surgery
The most effective form of surgery
One of the fixed instruments, but square
The law is complex and there are many complications
