Scoliosis
Introduction
Introduction to scoliosis Scoliosis is a pathological condition. When one or more segments of the spine are curved laterally, it can gradually increase, not only involving the spine, thoracic cage, ribs, and pelvis. In severe cases, it affects cardiopulmonary function and even involves the spinal cord, causing paraplegia. Scoliosis deformities specifically refer to deviations in the coronal position. Severe scoliosis requires surgical orthopedics, and mild scoliosis can be prevented or reduced by the physical therapy under the guidance of electrotherapy, traction therapy, and especially brace treatment. basic knowledge The proportion of illness: 0.0006% Susceptible people: no specific population Mode of infection: non-infectious Complications: spinal deformity
Cause
Cause of scoliosis
Scoliosis is a symptom that can cause scoliosis for a number of reasons, each with its own characteristics. In order to be effective, the type should be distinguished and targeted.
According to the cause, scoliosis can be divided into functional or organic, or non-structural and structural.
(a) non-structural scoliosis
1. Postural lateral bending;
2. Pain in the lower back, such as disc herniation, tumor;
3. Caused by unequal length of both lower limbs;
4. Hip contracture caused;
5. Inflammatory stimuli (such as appendicitis);
6. Hysteric scoliosis.
Non-structural scoliosis refers to temporary lateral bending caused by some reasons. Once the cause is removed, it can return to normal, but in the long-term existence, it can also develop into structural scoliosis. Generally, this kind of patient often disappears when lying down in the supine position. X-ray films are taken and the spine bones are normal.
(two) structural scoliosis
Idiopathic
The most common, accounting for 75%-85% of the total, the cause of the disease is not clear, so it is called idiopathic scoliosis. According to the age of onset, they can be divided into three categories.
(1) Infant type (0 to 3 years old) 1 Naturally cured type; 2 typed.
(2) Juvenile type (4 to 10 years old).
(3) Adolescent type (>10 years old - between skeletal maturity).
Among the above three types, teenagers are the most common.
2. Congenital
(1) Formation of a poor type 1 congenital hemivertebra; 2 congenital wedge-shaped vertebrae.
(2) Segmentation type.
(3) Mixed type, combining the above two types at the same time.
Congenital scoliosis is caused by the incomplete segmentation of the spine during the embryonic period, the incomplete development of the bone bridge on one side, or the incomplete development of one side of the vertebral body, resulting in asymmetry in the growth of both sides of the spine. Scoliosis. Often combined with other malformations, including spinal deformity, congenital heart disease, congenital urinary malformations, etc., generally found on the X-ray film of spinal deformity.
3. Neuromuscular
It can be divided into neurogenic and myogenic, which is due to neurological or muscular diseases leading to muscle imbalance, especially the scoliosis caused by left and right asymmetry of the paraspinal muscles. Common causes are sequelae of poliomyelitis, cerebral palsy, syringomyelia, progressive muscular atrophy, etc.
4. Neurofibromatosis with scoliosis.
5. Scoliosis caused by interstitial lesions
Such as Ma Fang syndrome, congenital polyarticular contracture and so on.
6. Acquired scoliosis
Scoliosis caused by thoracic surgery such as ankylosing spondylitis, spinal fractures, spinal tuberculosis, empyema and thoracoplasty.
7. Other reasons
Scoliosis caused by metabolic, nutritional or endocrine causes.
Prevention
Scoliosis prevention
Scoliosis is mainly for prevention. School-age children should maintain correct posture, strengthen the back muscles, abdominal muscles, diaphragm and shoulder muscles. Lightly correct by themselves, no need for treatment. For some of the spine caused by congenital factors. Convex, there are no effective preventive measures at present, early detection, early diagnosis, early treatment is the key.
Complication
Scoliosis complications Complications spinal deformity
Some patients with this disease have unintentionally found spinal deformity. The clinical malformation may not be obvious. In severe cases, the thoracic rotation deformity, the trunk tilt, the thoracic subsidence, the trunk shortening and the activity endurance due to the decrease of the thoracic volume decrease, and the shortness of breath, Heart palpitations, indigestion, loss of appetite and other visceral dysfunction, etc., scoliosis has not been effectively treated for a long time, and symptoms of spinal nerve traction or compression may occur.
Symptom
Symptoms of scoliosis Common symptoms Spinal curvature of the spine of the spine The angular deformity of the spine is affected by the size of the spinal canal. Lumbar stiffness and lumbar lordosis disappeared. Radioactive pain, dyspnea, torso deformity, curved palpitations
From the shape, the side bend can produce back bulge deformity, resulting in "razor back" deformity, and some even produce "funnel chest" or "chicken chest" deformity, combined with this back deformity, can be accompanied by bilateral shoulder joint imbalance or pelvis Unbalance, as well as unequal length of the lower limbs, can cause significant local deformity, reduced height, decreased chest and abdominal volume, and even damage to nerve function, respiratory function, digestive function, etc., and dysplasia of the spine bone structure itself. Patients may be associated with manifestations of neurodevelopmental abnormalities such as meningocele and stealth spina bifida. In addition, congenital scoliosis may also be associated with abnormal cardiovascular system, tracheal-esophageal fistula, polycystic kidney disease and other multiple organ abnormalities.
Examine
Scoliosis examination
The disease can have the following auxiliary inspection methods:
First, the ripple image inspection (Moiré topography)
The corrugated image is optically represented by the contour image to indicate the dorsal deformity of the spine. If the line from the spinous process of the neck 7 to the upper edge of the gluteal groove is used as the reference line, the normal corrugated image is symmetrically symmetrical on both sides of the reference line. The number is equal, such as deformity on the back, height difference on both sides, the number of corrugation grids is different and asymmetrical, the more severe the deformity, the greater the difference in height between the back sides, the greater the difference in the number of corrugations, if there is one or more The difference in the number of cells is positive for the ripple image.
Ordinary X-ray examination can not reflect the rib and thoracic deformity caused by spine rotation. The grating projection and corrugated imaging device for spine examination are used to photograph different corrugations of different heights or deformities on the back or waist of the patient. Ripple image, when placing the image, place the ruler on the body position frame, and take the same picture with the patient's back, so as to be the scale of the measurement calculation. For example, in the picture from the C7 spinous process to the gluteal groove, the middle line is drawn from top to bottom. For the peak points of each corrugation on both sides, find the two peaks with the shortest vertical spacing from the center line and the largest difference in the number of corrugations, set a and b (the convex side is a), a and b The height difference is H, and the distance between a and b is (a+b). According to the above punctuation, the rib bulge angle or the waist bulge angle can be obtained according to the formula, that is, the angle is used to represent the vertebral side. The convex deformation formed on the back side of the trunk, the actual length of a, b is w=a+b/scale, the height between a and b is H=a, and the difference between b is the number of ripples ×5 (each ripple spacing represents 5mm) The actual height difference), then the bulge angle (HA) = tan-1H / w. Therefore, the corrugated image is not only qualitative but also quantitative in judging the scoliosis.
Second, radiology examination
(1) Ordinary X-ray film inspection
It is the basic basis for the diagnosis and treatment of scoliosis as well as the physical examination. The X-ray film is used to understand the etiology, type, location, size, extent and flexibility of the scoliosis. According to different needs, other special X-ray examinations can be performed. Radiological examination to establish a diagnosis; observation of malformation progression; search for concurrent malformations; development of treatment plans, or evaluation of efficacy.
Upright position inspection
The standing position and the sitting position are like the basic posture of the X-ray examination. The standing position can be stood, the lack of standing function of the lower limbs or the sitting position of the younger ones, the standard posture, that is, the patient's feet are flush, the legs are straight, the torso Straighten, prevent rotation, cast the front piece, and extend the forearm 90° forward (or on the stand) to cast the lateral piece. Try to include a full length of the spine.
2. Flexibility check
After the lateral protrusion has been confirmed by the erect phase, the lateral flexion piece can be photographed to understand the bendability of each curvature of the spine, so that the patient can be supine, and the active contraction force of the muscle can be flexed to the convex side to correct the deformity. Some patients For neuromuscular scoliosis, muscles have no ability to contract spontaneously, and sometimes use "pushing" to film to understand their flexibility.
3. Traction under the film
The patient was placed in the supine position, and the occipital band and the pelvic belt were taken up and down at the same time. At present, it is more standard and commonly used for hanging under the suspension, that is, the occipital jaw is pulled upright (so that the patient's feet are just off the ground) Quasi) take a positive, lateral position to understand the flexibility of the scoliosis.
4. Spinal derotation (Stagnara phase)
Structural scoliosis, especially in severe scoliosis (above 100°), is often accompanied by spine rotation. Ordinary posterior anterior radiographs do not truly reflect the exact degree of deformity, and sometimes do not show true deformity of the vertebral body. The ideal method is to fluoroscopy under the screen, rotate the spine until the scoliosis reaches the maximum, or rotate to the vertebral vertebral vertebra to show the true orthophotos to show the true degree of curvature of the spine, or The true form of the vertebral body.
5. Evaluation of bone age
The treatment of scoliosis, the patient's age is one of the important reference factors, to understand the bone age to assess whether the bone continues to grow, the girl's growth and maturity is about 16 years old, the boy is 1 to 1 (1/2) years later than the girl, so Take the patient's left hand and the wrist's orthotopic X-ray film to understand the bone age. The current Risser method is to use the sacral humerus to understand the maturity of the epiphysis, and to treat the anterior superior iliac spine to the posterior superior iliac spine. The total length is divided into 4 segments, from the anterior to the posterior, the first 1/4 has 1 degree when the epiphysis appears, the first 1/2 has 2 degrees when the epiphysis grows, 3/4 is 3 degrees, and the total length is 4 degrees. The osteophyte is completely closed at 5 degrees, and its closure age is about 24 years old. It is the last epiphysis of the whole body closure. At this time, the bone growth and development has stopped, the scoliosis is relatively stable, and sometimes the clear chest can be referred to. X-ray film of the lumbar spine, observing the vertebral cartilage spasm, if the sputum is intermittent, indicating that the bone growth has not been completed, if it has been fused, the spine development has been completed.
(2) Tomography
The flat layer can provide a clear definition of the deformity, the extent and nature of the lesion, such as nonunion, or pseudoarticular formation in a specific area. Ordinary plain films may be unclear, while faults may be displayed.
(three) myelography
Scoliosis is not only to understand the spine or vertebral deformity, but also to understand the presence or absence of coexistence in the spinal canal. In congenital scoliosis, myelography is almost routinely examined. The purpose is to understand the nervous system that coexists with skeletal malformation. Abnormality, most of the contrast agents currently use Amipaque or Wmnipaque, because of its good contrast performance, safety, mild response, adult dose is 10 ~ 20ml, generally using lumbar puncture method, such as upswing, take the high head low position, the down check take the head high When the foot is low, but the head is low, the contrast agent is prevented from entering the ventricle under the display of the fluorescent screen.
(4) Electronic computed tomography (CT)
CT scan has obvious superiority in the diagnosis of spinal, spinal cord and nerve root lesions, especially for the unclear parts of the common silk phase (occipital neck, neck and thorax, etc.), because it is more distinguishable than ordinary X-ray density. 20 times higher, it can clearly show the fine structure of vertebrae, spinal canal and paravertebral tissue, especially CT scan of myelography, to understand the true situation in the spinal canal, to understand the relationship between bone and nerve components, for surgical treatment , can provide valuable information.
(5) Magnetic resonance imaging (MRI)
MRI is a new non-invasive multiplanar imaging examination. It has strong resolving power for intraspinal lesions. It not only provides the location and extent of the lesion, but its resolution such as edema, compression, hematoma, and spinal degeneration is superior to CT, but It is not a substitute for CT or myelography, and each has its own indications.
Third, electrophysiological examination
Electrophysiological examination is of great significance for understanding the presence or absence of nerves and muscle system disorders in patients with scoliosis.
(a) EMG examination
Electromyography is a bioelectric activity that occurs by striated muscle contraction, which is picked up by an electrode, amplified, displayed on a cathode ray oscilloscope, and drawn on a recording paper, and analyzed according to a single or overall figure of the myoelectric potential to understand the motion unit. The state, assessment and judgment of neuromuscular function, the patient takes the supine position during the examination, the skin of the site to be examined is disinfected, the sterilized needle electrode is inserted into the muscle to be examined, and the insertion potential at the time of insertion is observed, and the muscle is completely relaxed. The resting potential and the motor unit potential appearing during muscle contraction, such as fibrillation potential, positive or positive phase potential, beam shake potential, or biphasic potential are all abnormal electromyograms.
(B) nerve conduction velocity measurement
It can be divided into motion conduction velocity and sensory conduction velocity. The measurement of motion conduction velocity is to use current stimulation, record muscle potential, and calculate the speed of excitation along the motor nerve conduction, namely:
Motor nerve conduction velocity (m/s) = two-point spacing (mm) / two-point latency difference (ms).
The sensory nerve conduction velocity is measured by stimulating the finger or toe with a little forward direction, recording the excitation potential at the proximal end, and also stimulating the nerve trunk in the reverse direction, and recording the excitation potential at the finger or toe end. The calculation method is the same as above, and the influence factor of the conduction velocity is measured. More, such as unilateral lesions, with a healthy side control is appropriate.
(three) evoked potential check
Somatosensory evoked potential (SEP) has certain practical value in judging the degree of spinal nerve injury, estimating prognosis or observing the therapeutic effect. In recent years, we have directly placed the stimulation and recording electrodes in the arachnoid or epidural records in spinal surgery. Spinal cord evoked potential (SCEP), a segmental monitoring of the spinal cord, stable and clear waveforms, unaffected by anesthesia and drugs, can provide a better monitoring tool for spinal surgery.
Fourth, lung function test
Scoliosis causes thoracic deformity and respiratory muscle fatigue due to vertebral body rotation, and lung expansion is also limited. Therefore, scoliosis often has pulmonary dysfunction, the scoliosis is heavier, and the lung function is heavier. According to the author 105 For patients with scoliosis, preoperative pulmonary function tests were performed. All the patients except the 2 patients had different degrees of pulmonary dysfunction. The lung capacity was less than 50%, accounting for 16%, and the forced expiratory lung capacity was less than 50%, accounting for 30%. Normal chest or back surgery can reduce lung capacity by 10% to 15% due to postoperative pain. Therefore, patients with severe spinal deformity with less than 40% of lung capacity should first expand lung function before surgery and perform spinal orthopedics after pulmonary function improvement. surgery.
5. X-ray film measurement of scoliosis
(1) Side convex angle measurement
1. Cobb method in the positive X-ray phase, first determine the upper and lower end vertebrae of the scoliosis, on the upper end of the main curve, the upper end plate is inclined to the concave side, the uppermost end is the upper end vertebra, the lower end of the main curve For the lower end vertebra, a flat line is drawn on the upper edge of the upper vertebral body and the lower edge of the lower vertebral body. The two horizontal lines are each a vertical line, and the intersection angle of the two perpendicular lines is the Cobb angle. The protractor can measure its specific degree.
2. The Ferguson method is in the orthotopic X-ray film, and leads from the center point of the upper end vertebra to the center point of the apical vertebra, and then leads from the center point of the lower end vertebra to the center point of the apical vertebra. The complementary angle of the two lines is the Ferguson angle.
The first two methods are commonly used in the Cobb method, and are almost unified by the international community. However, it should be noted that in the follow-up of diagnosis and treatment, the same scoliosis of the same patient is measured by the same final scoliosis, otherwise the conditions are different and difficult to compare.
(two) spine rotation measurement
In structural scoliosis, often accompanied by the rotation of the spine, the method of measuring rotation is:
1. Taking the spinous process as the marker point: that is, in the orthotopic X-ray film, the spinous process is normal in the center of the vertebral body. For example, the midline of the vertebral body to the lateral edge of the vertebral body is divided into three equal parts, and the spine is rotated to the spinous process. Concave side offset, offset 1 aliquot is I° offset, offset 2 aliquots are II°, 3 equal parts are III°, and IV° beyond the vertebral body edge, such as the vertebral spine is off the vertebral midline The number of degrees converted into degrees, that is, if the spine is off the center line, if it is 1/3 of a half of the vertebral body, the degree of rotation is 15°, 2/3 is 30°, and the spine projection is 45° at the edge of the vertebral body.
2. Using the pedicle as the marker point (Moe method): On the orthotopic X-ray film, observe the position of the bilateral pedicle, and also divide the hemi- vertebral body into three equal parts. The normal pedicle is bilaterally symmetrical. Outside 1/3, if the vertebral body rotates, the pedicle is located in the middle 1/3 for I° rotation, the inner 1/3 is II° rotation, the pedicle is located at the midline for III° rotation, and the pedicle is rotated beyond the midline to The other side is IV° rotation, according to the author's quantitative measurement of the rotation of 328 vertebral bodies of patients with scoliosis and normal people, and compared with the corresponding X-ray phase Nash-Moe rotation, that is, Nash-MoeI° rotation The actual rotation angle of the vertebral body is 10.42±2.14 degrees, II° is 24.03±3.91 degrees, III° is 32.94±4.51 degrees, and IV° is 50 degrees or more.
3. Measurement of vertebral wedge shape change: Patients with scoliosis have increased heights on both sides of the vertebral body with the increase of the lateral curvature, that is, the wedge shape changes, and the height of the concave side of the vertebral body decreases, such as the normal orthotopic X-ray film. The height of the vertebral body is divided into 4 degrees. For example, the height of one side of the vertebral body is reduced by 0 to 1/6, and 1/6 to 1/3 is II°, and 1/3 to 1/2 is III. 2 is IV°.
All examinations should be documented for use in follow-up.
Diagnosis
Diagnosis and identification of scoliosis
First, medical history
The first visit to the patient should be asked in detail about the medical history, to understand the patient's mother's pregnancy, production, whether there is potential for fetal malformation in the first trimester of pregnancy, whether the family siblings have the same patient, whether there is diabetes, or scoliosis The age of emergence, the progress of bending, whether or not he has received treatment and what kind of treatment, what are the main symptoms now, such as fatigue, shortness of breath after exercise, difficulty breathing, palpitations, numbness of lower limbs, inconvenient walking, difficulty in urination, etc. Should be asked in detail, mild scoliosis, can be asymptomatic, especially in adolescent girls with good hair, chest and back is not easy to expose, deformity is often ignored, so the group census, careful physical examination is the key to early detection.
Second, physical inspection
The physical examination includes measuring the height, weight, sitting height, double-point position of the arms, and the middle fingertip spacing and other related items, and then being examined to expose the entire waist back, standing naturally, feet and shoulders are equal width, binocular head-up, arms naturally drooping, palm Inward, observe whether the shoulders of the examinee are symmetrical, whether the shoulders of the shoulders are at the same level, whether the waists are symmetrical on both sides, whether the sides are equal, and whether the spines are off the center axis, if there is more than one of the five items Abnormally listed as trunk asymmetry, and then the spine adam flexion test, the subject's knees straight, so that the trunk from the neck to the waist slowly bend forward, the examiner from the center of the back tangential direction to observe the upper thoracic segment, chest segment, chest Whether the lumbar and lumbar segments are equal in height, symmetrical, asymmetry is positive for the flexion test, suspected scoliosis).
At the same time as the spine flexion test, the examiner can measure the inclination of each segment of the back of the subject, or hump angle, using a scoliosis angle measuring instrument or a level meter, and record the maximum inclination angle and its position, if the back is asymmetrically inclined More than 4° is suspected of scoliosis.
Physical examination precautions: physical examination including flexion test is the basic examination method for scoliosis examination, especially the forefoot bending test is recognized as simple, sensitive and practical in the initial examination of scoliosis. Method, but in the specific application must pay attention to the following points:
1. The ground on which the subject is standing should be flat. If there are two lower limbs, the affected limb should be raised to make the pelvis flat.
2. The back of the inspected must be completely exposed and relaxed throughout the body.
3, the subject should face the light source, the side light in the back caused by shadows is prone to illusion.
4. When the flexion test is performed, the palms of the hands are relatively closed or the crossbar is held, so that the upper limbs naturally sag, and then slowly flexion to understand the full length of the spine.
The disease needs to be differentiated from congenital dislocation of the hip. Congenital hip dislocation is limited by abduction, and the nesting test is positive. The hip abduction activity is increased, and the Ober test is positive. It is easy to distinguish from congenital dislocation of the hip. .
