idiopathic scoliosis
Introduction
Introduction to idiopathic scoliosis Scoliosis, which is unclear during growth and development, is called idiopathic scoliosis. Idiopathic scoliosis is generally classified into three types according to age characteristics: infant type (0 to 3 years old); juvenile type (4~) 9 years old); youth type (10 to 16 years old). According to the anatomical position of the scoliosis vertebral column, it is further divided into: 1 neck bend: the apical vertebra is between C1 and C6. 2 neck and chest bending: the apical vertebra is between C7 and T1, 3 chest bending: the apical vertebra is between T2 and T11. 4 chest and waist: the vertebral vertebra is between T12 and L1. 5 waist bending: the vertebral vertebra is between L2 and L4, and the 6 lumbosacral curvature: the apical vertebra is at L5 or S1. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: atelectasis
Cause
Idiopathic scoliosis
Causes:
The cause is not yet clear. In 1979, Herman demonstrated that patients with idiopathic scoliosis had a labyrinthine impairment. In 1984, Yamada also performed a balanced function test on patients with idiopathic scoliosis. As a result, 79% showed significant balance dysfunction. Wyatt also found that patients with scoliosis had significant vibrational imbalances, suggesting a central disorder in the posterior column pathway of patients with scoliosis.
Pathogenesis:
The pathological changes of idiopathic scoliosis mainly include the following:
1. The vertebral body, spinous process, lamina and facet joints change the convex and concave side of the vertebral body, and rotate, the main vertebral body and spinous process rotate to the concave side, and the concave side pedicle becomes shorter and becomes shorter. Narrow, the lamina is slightly smaller than the convex side, and the spinous process is inclined to the concave side, so that the concave side spinal canal is narrowed. On the concave side, the small joint is thickened and hardened to form an epiphysis.
2. Changes in the ribs The rotation of the vertebral body causes the convex side ribs to move to the back side, causing the back back to protrude, forming a hump. In severe cases, it is called "razor-back", and the convex side ribs are separated from each other, and the gap is increased. The wide, concave side ribs are squeezed together and protrude forward, resulting in asymmetrical chest.
3. Intervertebral disc, muscle and ligament changes The concave side intervertebral space is narrowed, the convex side is widened, and the small muscle on the concave side is slightly contracted.
4. Changes in viscera Severe thoracic deformity causes deformation of the lungs. Due to alveolar atrophy, lung expansion is limited, excessive tension in the lungs causes obstruction of the circulatory system, and severe cases can cause pulmonary heart disease.
Prevention
Idiopathic scoliosis prevention
Slight scoliosis can be trained by posture, correct posture, and guide deep breathing exercise or swimming exercise, training chest muscles to correct deformities, students can use the single parallel bars for pull-up exercises during breaks, and often use at home Both hands grab the door, window frame, etc. for hanging and pulling, and at the same time need to go to a specialist hospital for treatment, close observation, close follow-up.
Complication
Idiopathic scoliosis complications Complications of atelectasis
Scoliosis not only causes deformity, collapse, pain and other symptoms of the trunk, which reduces its labor ability, can not participate in normal work, and causes great harm to the mental health of children, and can lead to disability, and the quality of life of patients decreases. It also causes some social problems, such as 76% of female patients are unmarried, and early or severe scoliosis can lead to lung dysplasia, atelectasis, cardiopulmonary insufficiency and paraplegia, making patients' life expectancy lower than normal, according to statistics The average life expectancy is 46.4 years old.
Symptom
Idiopathic scoliosis symptoms Common symptoms Back pain Spinal curvature of the spinal cord Lesions and lumbar lordosis disappeared Scoliosis Osteoporosis Hip dysplasia
Most of them are posture-oriented, and they occur in girls aged 6-7, and there are fewer boys. Early deformities are not obvious, and there is no change in the structure of the spine. It is easy to correct, but it is often overlooked. After the age of 10, the second epiphysis of the vertebral body develops rapidly, with 1-2 years of scoliosis, convex shoulder height, concave side shoulder low, easy to be identified for treatment. In severe cases, the thoracic deformity may be secondary, and the volume of the thoracic cavity is reduced, causing visceral dysfunction such as shortness of breath, palpitations, indigestion, and loss of appetite. Scoliosis has not been effectively treated for a long time, and symptoms of spinal nerve traction or compression may occur.
1. Infant idiopathic scoliosis
Infantile idiopathic scoliosis is a structural spinal deformity found within 3 years of age. This type is relatively common in Europe, and in the United States, this type is in patients with idiopathic scoliosis. Less than 1%, early diagnosis of infantile idiopathic scoliosis is very important, parents and pediatricians should closely observe this, because early treatment will affect the prognosis, so should be treated as soon as possible.
Characteristics: In 1954, James first recognized infantile scoliosis as a unique whole, and found that there are two situations in the natural course of disease, and according to this, it is divided into two types: self-limiting and progressive, and a large number of studies confirmed that the baby The characteristics of idiopathic scoliosis are as follows:
(1) The average male baby is more common, usually the side bends to the left.
(2) The lateral curvature is generally located in the thoracic segment and the thoracolumbar segment.
(3) Most scoliosis progresses within 6 months after birth.
(4) Self-limited infantile idiopathic scoliosis accounts for 85% of all infantile idiopathic scoliosis.
(5) Double thoracic flexion is easy to progress and develops into severe deformity. Female patients with right thoracic curve usually have a poor prognosis and are often accompanied by malformations (flat head deformity, bat ear malformation, congenital torticollis, and progressive hip development). Bad, etc.).
2. Children's idiopathic scoliosis
Juvenile idiopathic scoliosis is a scoliosis deformity found between the ages of 4 and 10 years. It accounts for 12% to 21% of idiopathic scoliosis, and the cause is unknown.
Characteristics: Compared with infantile and adolescent idiopathic scoliosis, juvenile idiopathic scoliosis is characterized by a relatively stationary phase of spine growth, which scholars know about its scoliosis type and natural history. Very few, only by finding the age of the deformity rather than by symptoms, signs, etc., how to diagnose the child with idiopathic scoliosis has become the focus of discussion, patients diagnosed with juvenile type are likely to be late-onset infants Adolescent idiopathic scoliosis with idiopathic scoliosis or early onset is artificially diagnosed as a juvenile type.
Children are more common in girls. The ratio of female to male is about 2 to 4:1. In children aged 3 to 6, the ratio of female to male is about 1:1. In the age of 6 to 10, female and male are about 8:1, this value is basically the same as adolescent idiopathic scoliosis.
The types of juvenile scoliosis are mostly right thoracic and double main bends. The right thoracic curve accounts for 2/3 of the youth type IS, the double main bend accounts for about 20%, and the thoracolumbar scoliosis accounts for 15%. Bending is not common in juvenile types. If this kind of scoliosis occurs, it often indicates the presence of intraspinal lesions, and a comprehensive neurological examination should be performed.
The natural history of adolescents is relatively better, but the children's type is more invasive. It can progress to severe deformity and impair lung function. About 70% of juvenile idiopathic scoliosis is progressively aggravated and needs to be given. Formal treatment, because the juvenile spine still has growth potential, so in theory, the scoliosis must progress, but the study by Mannherz et al found that the left chest bend or the left lumbar bend is most likely to self-resolved, which also shows that some children Type scoliosis can also subside or progress slowly, but the rate of self-reduction is not high relative to infants.
3. Juvenile idiopathic scoliosis
Idiopathic scoliosis is relatively common. Adolescents in the 10-16 age group have an incidence of about 2% to 4%, and most of the scoliosis is small. In patients with scoliosis of about 20°, the ratio of male to female Basically equal; in the scoliosis population greater than 20°, the female: male exceeds 5:1, the fact that female scoliosis is more serious suggests that female scoliosis may be more progressive, and they need treatment more than boys. .
Most adolescent idiopathic scoliosi (AIS) patients can live normally. In some cases, the progression of AIS scoliosis is often accompanied by decreased lung function and back pain. If the chest bend is greater than 100°, Forced vital capacity usually drops to 70% to 80% of the expected value. The decline in lung function is usually secondary to restrictive lung disease. If severe scoliosis impairs lung function, the patient may die from pulmonary origin in the early stage. Heart disease, some scholars have statistics, the mortality rate of patients with severe scoliosis is twice that of the general population, the risk of death in smoking patients is increased, and the intermittent back pain of moderate scoliosis (40 ° ~ 50 °) The incidence rate is almost the same as that of the general population. The incidence of severe lumbar scoliosis is high, and the incidence of apical vertebrae is significantly higher.
Examine
Examination of idiopathic scoliosis
Routine examination of blood routine, urine routine, creatinine, urea nitrogen, blood sugar, etc., X-ray examination is an indispensable routine examination of scoliosis, generally can distinguish the classification of the scoliosis, classification, convexity, spine rotation, The degree of compensability and softness often include the full length of the spine in the standing position, the positive position in the supine position, the left and right lateral flexion, and the traction position.
1. X-ray examination of scoliosis
(1) The upright position of the full spine is positive, the lateral position is like: the upright position is full of the spine, and the lateral position is the most basic means of diagnosis. The X-ray image needs to include the entire spine. When the X-ray film is taken, the upright position must be emphasized. If the patient can't stand upright, it is better to use the sitting position to reflect the true situation of scoliosis.
(2) Bending of the spine: The bending of the spine includes the supine position and the curved image of the supine position. Currently, the supine position is the most widely used, mainly for:
1 Evaluation of the activity of the intervertebral space of the lumbar curve.
2 Determine the lower fixed vertebra.
3 predict the flexibility of the spine.
However, supine position bending is less effective in predicting spinal flexibility because scoliosis orthopedic surgery is performed under general anesthesia, and muscle relaxants are used during surgery to eliminate the effect of muscle contraction against orthopedics; posterior orthopedic surgery In the process, it is necessary to peel off the paravertebral muscles on both sides, which plays an indirect role of spinal decompression to some extent. Bending needs active coordination of patients, and its influencing factors are more, the age of the patient, the degree of education, etc. It may affect the effectiveness of this test, especially for patients with mental disorders or neuromuscular disorders.
(3) Suspension traction image:
1 The role of the suspension traction image:
A. It can provide a complete picture of the scoliosis traction reduction.
B. For patients with impaired neuromuscular function.
C. Suitable for evaluating torso offset and upper thoracic curve.
D. The level of the lower fixed vertebra can be estimated.
2 Note: Before the examination, you should carefully ask each patient whether there is a cervical disease.
3 contraindications: reflect the softness of the elderly or osteoporosis patients.
(4) fulcrum bending image: fulcrum bending radiograph is to make the patient side on the plastic cylinder, the cylinder is placed on the corresponding rib of the thoracic vertebrae, the operation requirements are:
1 full lateral position.
2 Select a cylinder of appropriate size (cylinder diameter 14 cm, 17 cm, 21 cm, respectively) to leave the shoulders away from the bed.
The characteristics of the fulcrum bending image: easy to operate, the bending force is passive force, the repeatability is good, can truly reflect the degree of stiffness of the side curve, predict the correction degree of the side curve, can also be used to determine whether some cases need anterior lysis The fulcrum bending is more effective for patients with stiff lateral curvature.
(5) oblique image: used to check the condition of spinal fusion, lumbosacral oblique image for spinal spondylolisthesis, isthmic fissure patients.
(6) Ferguson image: Ferguson is used to check the joint of the lumbosacral joint. In order to eliminate the lumbar lordosis, the male tube is tilted 30° to the head side and the woman is tilted 35°, so that the true lumbosacral joint image can be obtained. .
(7) Stagnaara image: Stagnaara image for patients with severe scoliosis (greater than 100 °), especially with kyphosis, vertebral body rotation, ordinary X-ray image is difficult to see ribs, transverse process and vertebral deformity It is necessary to take a rotating image to obtain a true anterior-posterior image, rotate the patient under fluoroscopy, and take a film when the maximum curvature occurs. The film is parallel to the inner side of the rib bulge, and the tube is perpendicular to the plaque.
(8) Fault images: The tomographic images are used to examine congenital malformations with unclear lesions, fusion of bone grafts, and certain special lesions such as osteoid osteomas.
(9) Cut image: The patient bends forward, and the tube is tangent to the back, which is mainly used to check the ribs.
(10) myelography: unconventional application, indications are congenital scoliosis or spinal cord compression, spinal cord mass, suspected lesions in the dural sac, X-ray image see pedicle distance widened, spinal canal insufficiency , spinal cord longitudinal fissure, syringomyelia, and planned resection of the hemivertebra or a semi-vertebral wedge resection to understand spinal cord compression.
(11) CT and MRI examination: it is very helpful for patients with spinal cord lesions, such as spinal cord fissure, syringomyelia, etc. It is very important to understand the plane and extent of the epiphysis for surgical orthopedics, resection of the epiphysis and prevention of paraplegia, but It is expensive and should not be routinely checked.
2. X-ray measurement of scoliosis
(1) Reading points of X-ray film:
1 end vertebra: the most apical and caudal vertebral body in the curvature of scoliosis.
2 vertebral vertebrae: the most severe deformity in the curvature, the vertebral body farthest from the vertical line.
3 main side bend (primary side bend): is the earliest curvature, is also the largest structural bending, poor flexibility and correctability.
4 times side bend (compensatory side bend or secondary side bend): is the smallest bend, the elasticity is better than the main side bend, it can be structural or non-structural, located above or below the main side bend, The role is to maintain the body's normal line of force, the vertebral body usually does not rotate, when there are 3 bending, the middle bend is often the main side bend, when there are 4 bends, the middle two are double main side bends.
(2) Scoliosis measurement of scoliosis:
1Cobb method: the most commonly used, the angle between the vertical line of the superior vertebrae of the cephalic end and the vertical line of the lower edge of the caudal end is the Cobb angle. If the upper and lower edges of the vertebrae are unclear, the upper and lower edges of the pedicle may be taken. Connect the line and then take the intersection angle of the vertical line as the Cobb angle.
2Ferguson method: rarely used, sometimes used to measure mild lateral curvature, find the midpoint of the vertebral body of the end vertebrae and the apical vertebrae, and then draw two lines from the midpoint of the apical vertebra to the upper and lower vertebrae, the angle of intersection It is the side bend angle.
(3) Measurement of scoliosis rotation: The Nash-Moe method is usually used: according to the position of the pedicle on the orthotopic X-ray, it is divided into 5 degrees.
I degree: pedicle symmetry.
II degree: the convex side pedicle moves to the midline, but does not exceed the first grid, and the concave side pedicle becomes smaller.
III degree: the convex side pedicle has moved to the second grid, and the concave side pedicle disappears.
IV degree: the convex pedicle is moved to the center, and the concave side pedicle disappears.
V degree: the convex side pedicle passes over the midline and is close to the concave side.
X-ray evaluation parameters: the posterior vertebrae, the superior vertebrae, the apical offset, and the sacral center perpendicular (CSVL).
3. Identification of scoliosis maturity
The evaluation of maturity is especially important in the treatment of scoliosis. It must be comprehensively evaluated according to physiological age, actual age and bone age, including the following aspects:
(1) Secondary sexual characteristics: the boy's voice changes, the girl's menarche, and the development of the breast and pubic hair.
(2) Bone age:
1 Wrist bone age: For patients under the age of 20, wrist X-ray films can be taken, and bone age is determined according to the criteria of Greulich and Pyle.
2excursion of iliac apophyses: Risser divides the iliac spine into 4 equal parts, and the ossification moves from the anterior superior iliac spine to the posterior superior iliac spine. The epiphysis moves 25% to I degree and 50% to II degree. 75% is III degree, and the upper spine is IV degree after moving to the iliac crest, and the epiphysis and tibia are fused to V degree.
3 vertebral ankle ring development: lateral X-ray film on the epiphyseal ring and vertebral body fusion indicates that the spine stops growing, an important indication for bone maturation.
4. Pulmonary function test of scoliosis
Pulmonary function tests were divided into 4 groups: resting lung volume; dynamic lung volume; alveolar ventilation; radioactive sputum study, the first three experiments were routinely used in patients with scoliosis.
Resting lung capacity includes total lung volume, lung capacity and residual capacity. The vital capacity is expressed as a percentage of the predicted normal value. 80% to 100% is normal lung capacity, 60% to 80% is mildly restricted, and 40% to 60% is moderately restricted. Less than 40% is a severe limit.
The most important of the dynamic vital capacity is the 1 second lung capacity (FEV1), which is compared to the total lung capacity, with a normal value of 80%.
The total lung volume and vital capacity of patients with scoliosis are reduced, while the amount of residual gas is normal, and unless it is advanced, the reduction in lung capacity is related to the severity of the scoliosis.
5. X-ray inspection
Spinal cord abnormalities cannot be directly indicated. Further imaging studies require evaluation of spinal canal contents and soft tissue around the spine to detect possible spinal cord abnormalities. Before MRI, myelography, CT, CT myelography is to evaluate spinal cord and surrounding soft tissue. The better method, after the appearance of MRI, because of its non-invasive, non-radioactive, high soft tissue contrast, gradually replaced myelography, CT, CT myelography, in the diagnosis of spinal deformity, MRI has superior soft tissue contrast, able to Direct display of all spinal cord and spinal canal, and can provide multi-planar images, the following briefly describes the common spinal cord abnormalities such as syringomyelia and Chiari malformation.
Diagnosis
Diagnosis and diagnosis of idiopathic scoliosis
Early diagnosis of scoliosis is essential for early treatment. Therefore, it is necessary to improve the census work of primary school students and preventive prevention.
1. The history of scoliosis is inquired in detail about all conditions related to spinal deformity, such as the patient's health status, age and sexual maturity, etc., also need to pay attention to past history, surgical history and trauma history, should understand the deformity of the child's mother during pregnancy Health status, history of medication during the first 3 months of pregnancy, pregnancy, complications during childbirth, family history should pay attention to other people with spinal deformity, neuromuscular scoliosis, family history is especially important .
2. Physical examination of scoliosis pays attention to three important aspects: deformity, etiology and complications.
Fully exposed, only wear shorts and loose outer garments at the back, pay attention to the pigmentation of the skin, whether there are coffee spots and subcutaneous tissue masses, whether the hair is too long and cystic on the back, pay attention to the development of the breast, whether the thorax is symmetrical, Without funnel chest, chicken breast, rib bulge and surgical scar, the examiner should carefully observe from the front, side and back.
The examiner first needs to know about the signs of early mild scoliosis, from the back of the patient:
(1) The shoulders are not equal.
(2) The shoulders are high and low.
(3) One side of the waist wrinkled skin.
(4) When the lumbar flexion is asymmetrical on both sides of the back, that is, the razor is crossed.
(5) The spine deviates from the midline.
Although scoliosis is a lateral curvature of the spine, the scoliosis is usually accompanied by a rotation and produces a typical paravertebral rib hump, the rotation of the torso, the ridge of the apical vertebral and paraspinal muscles is The visible deformity of scoliosis, the Adam flexion test is often used to screen for paraspinal deformities of scoliosis, as follows: the patient faces the examiner, the patient bends forward until the trunk is parallel to the horizontal plane, and the back is symmetrical, one side is raised Explain the rib and vertebral rotation deformity, you need some experience to determine the obvious paravertebral rotation. Bunnell has designed the scoliosis measuring ruler to improve its accuracy. The measuring ruler is placed on the scoliosis spine of the scoliosis. The angle of trunk rotation (ATR) is measured. The angle of rotation of the torso is related to the severity of scoliosis. Many spine surgeons recommend that if the ATR is greater than 5°, there is a trunk rotation and, at the same time, The distance between the rib angles on both sides and the tibia can be measured. The plumb line can also be placed from the spinous process of the neck 7 and then the distance from the gluteal groove to the vertical line can be measured to indicate the deformity. degree.
Then, check the range of flexion, over-extension and lateral bending of the spine, and check the flexibility of each joint, such as the proximity of the wrist and thumb, the over-extension of the fingers, the knee and the flexion of the elbow joint.
Finally, the nervous system should be carefully examined, especially in the lower limbs. It should be confirmed whether there is damage in the nervous system. If the patient has obvious muscle weakness, it is necessary to find out whether there is a potential neurological abnormality. It is not the sign of all patients with neurological damage. They are very obvious and may be only minor signs, such as asymmetry of the abdominal wall, slight clonic or extensive muscle weakness. However, these signs suggest that the nervous system should be examined in detail. The authors recommend MRI scan of the whole spinal cord, along with MRI and other examinations. Application and popularization, the author has been able to diagnose central nervous system malformations that were previously difficult to detect, such as hydromyelia and tethered cord. The hydrocephalus is mostly left-sided, so it is recommended for all left-hand bends. MRI is performed in patients with scoliosis, and the possibility of central nervous system disorders should be considered for each patient.
For patients suspected of having mucopolysaccharidosis, attention should be paid to the cornea, and patients with Mafang syndrome should pay attention to their upper jaw.
The patient's height, weight, arm spacing, and length of both lower limbs are all documented.
Infantile idiopathic scoliosis: Infant scoliosis needs to be differentiated from congenital scoliosis, neuromuscular scoliosis, and scoliosis secondary to intraspinal lesions, so detailed physical examination must be performed, and Record the presence of oblique head deformities and limb deformities.
At the first visit, the full length of the spine should be taken, and the lateral radiographs should be evaluated. The Cobb angle and the rib-vertebral angle difference (RVAD) should be evaluated. Except for the congenital vertebral deformity, before the baby can stand, The full-length positive image examination of the supine spine was used to find out whether there was fusion and instability of the cervical vertebra, and whether there were congenital malformations and hip dysplasia in the lumbosacral region and hip.
The vast majority of infants diagnosed with scoliosis have subtle neurological symptoms that suggest further examination. For example, the only clue to the diagnosis of Chiari malformation may be the absence of abdominal wall reflexes. In fact, true idiopathic infants Scoliosis is rare. Due to the high incidence of neurological malformations and the need for treatment, even if the neurological examination of patients in this age group is normal, full spine MRI should be performed routinely. For all infants requiring active treatment, MRI examination of the brain and spinal cord, Gupta et al. and Lewonowski found that patients with normal neurological examination of the scoliosis found some people with neurological malformations on MRI.
Juvenile idiopathic scoliosis: Mehta and Morel classify juvenile idiopathic scoliosis into the following categories: 1 night with regressive infant type, 2 benign progressive infant type, 3 with symptomatic scoliosis, 4 Spiral sinus scoliosis, a young type found early in 5 years.
Before definitive diagnosis, the cause of scoliosis must be clarified. The nervous system should be carefully examined. Sometimes the disappearance of abdominal wall reflex is the only clue to the diagnosis of Chiari malformation. Although most patients with IS have normal neurological examination, their spinal lesions are relatively High incidence, therefore, some scholars recommend routine MRI examination of all children with scoliosis, Gupta study found that the incidence of axonal deformity in asymptomatic children with idiopathic scoliosis is 18% to 20 %, at this age, scoliosis may be one of the initial signs of a potential nerve axis malformation.
Continuous Cobb angle measurements can determine whether scoliosis is progressing, and factors associated with progression of juvenile IS scoliosis are the increase in RVAD of the main vertebrae, chest thoracic less than 20°, and the left lateral curvature of the boy's spine, Kahanovitz et al. The Cobb angle greater than 45° when scoliosis is found is a risk factor for scoliosis. Continuous measurement of RVAD helps predict the long-term efficacy of brace treatment.
3. X-ray examination of scoliosis
(1) The upright position of the full spine is positive, the lateral position is like: the upright position is full of the spine, and the lateral position is the most basic means of diagnosis. The X-ray image needs to include the entire spine. When the X-ray film is taken, the upright position must be emphasized. If the patient can't stand upright, it is better to use the sitting position to reflect the true situation of scoliosis.
(2) Bending of the spine: The bending of the spine includes the supine position and the curved image of the supine position. Currently, the supine position is the most widely used, mainly for:
1 Evaluation of the activity of the intervertebral space of the lumbar curve.
2 Determine the lower fixed vertebra.
3 predict the flexibility of the spine.
However, supine position bending is less effective in predicting spinal flexibility because scoliosis orthopedic surgery is performed under general anesthesia, and muscle relaxants are used during surgery to eliminate the effect of muscle contraction against orthopedics; posterior orthopedic surgery In the process, it is necessary to peel off the paravertebral muscles on both sides, which plays an indirect role of spinal decompression to some extent. Bending needs active coordination of patients, and its influencing factors are more, the age of the patient, the degree of education, etc. It may affect the effectiveness of this test, especially for patients with mental disorders or neuromuscular disorders.
(3) Suspension traction image:
1 The role of the suspension traction image:
A. It can provide a complete picture of the scoliosis traction reduction.
B. For patients with impaired neuromuscular function.
C. Suitable for evaluating torso offset and upper thoracic curve.
D. The level of the lower fixed vertebra can be estimated.
2 Note: Before the examination, you should carefully ask each patient whether there is a cervical disease.
3 contraindications: reflect the softness of the elderly or osteoporosis patients.
(4) The fulcrum bending image:
The fulcrum bending radiograph is such that the patient lies on the plastic cylinder on the side and the cylinder is placed on the corresponding rib of the thoracic vertebrae. The operation requirements are:
1 full lateral position.
2 Select a cylinder of appropriate size (cylinder diameter 14 cm, 17 cm, 21 cm, respectively) to leave the shoulders away from the bed.
The characteristics of the fulcrum bending image: easy to operate, the bending force is passive force, the repeatability is good, can truly reflect the degree of stiffness of the side curve, predict the correction degree of the side curve, can also be used to determine whether some cases need anterior lysis The fulcrum bending is more effective for patients with stiff lateral curvature.
(5) oblique image: used to check the condition of spinal fusion, lumbosacral oblique image for spinal spondylolisthesis, isthmic fissure patients.
(6) Ferguson image: Ferguson is used to check the joint of the lumbosacral joint. In order to eliminate the lumbar lordosis, the male bulb is tilted 30° to the head side and the female is tilted 35° to obtain a true orthodontic lumbosacral joint image.
(7) Stagnaara image: Stagnaara image for patients with severe scoliosis (greater than 100 °), especially with kyphosis, vertebral body rotation, ordinary X-ray image is difficult to see ribs, transverse process and vertebral deformity It is necessary to take a rotating image to obtain a true anterior-posterior image, rotate the patient under fluoroscopy, and take a film when the maximum curvature occurs. The film is parallel to the inner side of the rib bulge, and the tube is perpendicular to the plaque.
(8) Fault images: The tomographic images are used to examine congenital malformations with unclear lesions, fusion of bone grafts, and certain special lesions such as osteoid osteomas.
(9) Cut image: The patient bends forward, and the tube is tangent to the back, which is mainly used to check the ribs.
(10) myelography: unconventional application, indications are congenital scoliosis or spinal cord compression, spinal cord mass, suspected lesions in the dural sac, X-ray image see pedicle distance widened, spinal canal insufficiency , spinal cord longitudinal fissure, syringomyelia, and planned resection of the hemivertebra or a semi-vertebral wedge resection to understand spinal cord compression.
(11) CT and MRI examination: it is very helpful for patients with spinal cord lesions, such as spinal cord fissure, syringomyelia, etc. It is very important to understand the plane and extent of the epiphysis for surgical orthopedics, resection of the epiphysis and prevention of paraplegia, but It is expensive and should not be routinely checked.
4. X-ray measurement of scoliosis
(1) Reading points of X-ray film:
1 end vertebra: the most apical and caudal vertebral body in the curvature of scoliosis.
2 vertebral vertebrae: the most severe deformity in the curvature, the vertebral body farthest from the vertical line.
3 main side bend (primary side bend): is the earliest curvature, is also the largest structural bending, poor flexibility and correctability.
4 times side bend (compensatory side bend or secondary side bend): is the smallest bend, the elasticity is better than the main side bend, it can be structural or non-structural, located above or below the main side bend, The role is to maintain the body's normal line of force, the vertebral body usually does not rotate, when there are 3 bending, the middle bend is often the main side bend, when there are 4 bends, the middle two are double main side bends.
(2) Scoliosis measurement of scoliosis:
1Cobb method: the most commonly used, the angle between the vertical line of the superior vertebrae of the cephalic end and the vertical line of the lower edge of the caudal end is the Cobb angle. If the upper and lower edges of the vertebrae are unclear, the upper and lower edges of the pedicle may be taken. Connect the line and then take the intersection angle of the vertical line as the Cobb angle.
2Ferguson method: rarely used, sometimes used to measure mild lateral curvature, find the midpoint of the vertebral body of the end vertebrae and the apical vertebrae, and then draw two lines from the midpoint of the apical vertebra to the upper and lower vertebrae, the angle of intersection It is the side bend angle.
(3) Measurement of scoliosis rotation: The Nash-Moe method is usually used: according to the position of the pedicle on the orthotopic X-ray, it is divided into 5 degrees.
I degree: pedicle symmetry.
II degree: the convex side pedicle moves to the midline, but does not exceed the first grid, and the concave side pedicle becomes smaller.
III degree: the convex side pedicle has moved to the second grid, and the concave side pedicle disappears.
IV degree: the convex pedicle is moved to the center, and the concave side pedicle disappears.
V degree: the convex side pedicle passes over the midline and is close to the concave side.
X-ray evaluation parameters: the posterior vertebrae, the superior vertebrae, the apical offset, and the sacral center perpendicular (CSVL).
5. Identification of scoliosis maturity The evaluation of maturity is particularly important in the treatment of scoliosis. It must be comprehensively evaluated according to physiological age, actual age and bone age, including the following aspects:
(1) Secondary sexual characteristics: the boy's voice changes, the girl's menarche, and the development of the breast and pubic hair.
(2) Bone age:
1 Wrist bone age: For patients under the age of 20, wrist X-ray films can be taken, and bone age is determined according to the criteria of Greulich and Pyle.
2excursion of iliac apophyses: Risser divides the iliac spine into 4 parts, and the ossification moves from the anterior superior iliac spine to the posterior superior iliac spine. The epiphysis moves 25% to I degree, 50% is II degree, 75 % is III degree, and the upper spine is IV degree after the movement to the iliac crest, and the epiphysis and the tibia are fused to V degree.
3 vertebral ankle ring development: lateral X-ray film on the epiphyseal ring and vertebral body fusion indicates that the spine stops growing, an important indication for bone maturation.
6. Laboratory examination of scoliosis routinely check blood routine, urine routine, creatinine, urea nitrogen, blood sugar and so on.
7. Pulmonary function of scoliosis Pulmonary function tests were divided into 4 groups: resting lung volume; dynamic lung volume; alveolar ventilation; radioactive sputum study, the first three experiments were routinely used in patients with scoliosis.
Resting lung capacity includes total lung volume, lung capacity and residual capacity. The vital capacity is expressed as a percentage of the predicted normal value. 80% to 100% is normal lung capacity, 60% to 80% is mildly restricted, and 40% to 60% is moderately restricted. Less than 40% is a severe limit.
The most important of the dynamic vital capacity is the 1 second lung capacity (FEV1), which is compared to the total lung capacity, with a normal value of 80%.
Differential diagnosis
(1) Congenital scoliosis: due to abnormal development of the spine embryo, the disease is earlier, most of which is found in infants and young children. The pathogenesis is structural abnormality of the spine and imbalance of spinal growth. The differential diagnosis is not difficult. X-ray film can be found to have structural deformities in the spine. Basic deformities can be divided into three types: 1. Spinal formation disorders, such as hemivertebrae; 2. Spinal segmentation, such as unilateral unsectioned bone bridges; , mixed type, such as conventional X-ray film difficult identification, available CT.
(B) neuromuscular scoliosis: can be divided into neurological and myogenic, the former includes cerebral palsy of upper motor neuron lesions, syringomyelia and other cerebral palsy of lower motor neuron lesions, etc., the latter includes Muscular dystrophy, myasthenia, etc. The pathogenesis of this type of scoliosis is caused by the loss of control of the balance of the spine and trunk of the nervous system and muscles. The cause of this disease often requires careful clinical examination to detect, sometimes A neuromuscular electrophysiology or even a neuromuscular biopsy can be used to confirm the diagnosis.
(C) neurofibromatosis complicated by scoliosis: neurofibromatosis is an autosomal hereditary disease caused by a single genetic disease (but 50% of patients are from genetic mutations), 2% to 36% of patients with Scoliosis can be diagnosed when the clinical criteria meet the following two criteria. 1. Patients with pre-mature birth have more than 6 skin coffee spots with a diameter of 5 mm or more or a diameter of more than 15 mm after maturity; 2, 2 Any of the above forms of neurofibromatosis or plexus neurofibroma; 3, freckle in the axillary or inguinal skin; 4, optic glioma; 5, more than two scleral hamartomas (Lisch nodules); 6, bone Lesions, such as long cortical bone thinning; 7, family history, patients with scoliosis, X-ray features can be similar to idiopathic scoliosis, can also be expressed as "dystrophic" scoliosis, that is, short sections The angling type of posterior protrusion of the segment, the severe rotation of the spine, the depression of the vertebral body, etc., such scoliosis continues to progress, the treatment is difficult, and the incidence of pseudoarthrosis is high.
(D) mesenchymal lesions complicated by scoliosis: sometimes Marfan syndrome, EhlerS-Danlos syndrome, etc. can be based on scoliosis, detailed physical examination can find other clinical symptoms of these diseases, such as ligament relaxation, chicken breast or funnel Chest and so on.
(5) Osteochondral dystrophy complicated by scoliosis: such as various types of strains of the genus, spinal myelodysplasia.
(6) Metabolic disorders associated with scoliosis: such as various types of mucopolysaccharidosis, homocystinuria and the like.
(7) "Functional" or "non-structural" scoliosis: This type of scoliosis can be caused by irregular posture, nerve root stimulation, and unequal length of the lower limbs. If the original cause can be removed early, the scoliosis can be eliminated by itself. However, it should be noted that a small number of adolescent idiopathic scoliosis may be mistaken for "correct posture" in the early stage because of the small degree, so the so-called "functional" scoliosis before puberty should be closely followed.
(8) Scoliosis for other reasons: such as radiotherapy, extensive laminectomy, infection, and tumor can cause scoliosis.
Pay attention to the safety of production and life, and avoid trauma is the key to the prevention and treatment of this disease.
