Scoliosis in children
Introduction
Introduction Scoliosis, whose cause is unclear during growth and development, is called idiopathic scoliosis. According to the age characteristics, idiopathic scoliosis is generally divided into three types: infant type (0 to 3 years old); juvenile type (4 to 9 years old); and 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 bend: the apical vertebra is between L2 ~ L4. 6 lumbosacral curvature: the apical vertebra is at L5 or S1.
Cause
Cause
(1) Causes of the disease
Because idiopathic scoliosis accounts for the vast majority of scoliosis, if it can understand its cause, it is of great significance for prevention and treatment. Therefore, people have been working on the cause of idiopathic scoliosis for many years, but the exact cause has not been found so far.
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. Results showed that 79% showed significant balance dysfunction, compared with 5% in the control group. Wyatt also found that patients with scoliosis had significant vibrational imbalances, suggesting a central disorder in the posterior column pathway of patients with scoliosis. However, these studies did not clarify the relationship between idiopathic scoliosis and balance disorders, and did not explain the etiology of idiopathic scoliosis itself.
It was observed that the height of patients with idiopathic scoliosis was higher than that of normal peers. The author's 1984 census is also the result. This prompted people to understand the relationship between growth hormone and idiopathic scoliosis. The results of different authors have different conclusions, and the growth hormone content is still a matter of debate. More literature discusses the relationship between paravertebral muscles and idiopathic scoliosis. The detection of paraspinal muscles includes: muscle spindle, muscle fiber morphology, muscle biochemistry, myoelectricity, calcium, copper, and zinc. Although there were abnormal findings, they did not directly explain the cause. People have also investigated genetic problems from familial investigations, and patients with sacral scoliosis have been investigated, but more patients cannot be explained by a single genetic abnormality. Therefore, the cause of idiopathic scoliosis is still being explored in the future. Important topic.
(two) pathogenesis
The pathological changes of idiopathic scoliosis mainly include the following:
1. Changes in vertebral body, spinous process, lamina and facet joints: The vertebral body of the scoliosis is wedge-shaped and rotates, and the vertebral body and spinous process of the main side are rotated to the concave side. The concave side pedicle becomes shorter and narrower, and the lamina is slightly smaller than the convex side. The spinous process is inclined to the concave side to narrow the concave side spinal canal. On the concave side, the facet joint thickens and hardens 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, which is called "razor-back". The convex side ribs are separated from each other and the gap is widened. The concave side ribs are squeezed together and protrude forward, resulting in asymmetrical chest.
3. Changes in intervertebral disc, muscle and ligament: the concave side intervertebral space is narrowed, the convex side is widened, and the small muscle on the concave side is slightly contracted.
4. Visceral changes: 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.
Examine
an examination
Related inspection
X-ray lipiodol angiography palpation
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 less than 1% in patients with idiopathic scoliosis. Early diagnosis of infantile idiopathic scoliosis is important, and parents and pediatricians should closely observe this. Because early treatment can affect the prognosis, it 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 cases of natural disease, and according to this, it is divided into two types: self-limiting and progressive. A large number of studies have confirmed that the characteristics of infantile 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 chest 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 deformity, congenital torticollis, and progressive hip development). Bad, etc.).
2. Juvenile idiopathic scoliosis: juvenile idiopathic scoliosis is a scoliosis deformity found between 4 and 10 years old, which accounts for 12% of idiopathic scoliosis~ 21%, the cause is unknown.
Characteristics: Compared with infantile and adolescent idiopathic scoliosis, juvenile idiopathic scoliosis is characterized by a relatively quiescent progression of spinal growth. Scholars know little about its type of scoliosis and natural history. It is only diagnosed by finding the age of the deformity rather than by symptoms and signs. Therefore, how to diagnose the juvenile idiopathic scoliosis has become the focus of discussion. Patients diagnosed with a juvenile type are likely to have advanced onset infantile idiopathic scoliosis or early onset adolescent idiopathic scoliosis that 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. The ratio of female to male is about 1:1 for children aged 3 to 6 years. 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 chest bend accounts for 2/3 of the youth type IS, the double main bend accounts for about 20%, and the thoracolumbar scoliosis accounts for 15%. The left chest curve is not common in the juvenile type. 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 juvenile type is more invasive, and it can progress to severe deformity and impair lung function. Approximately 70% of juvenile idiopathic scoliosis is progressively exacerbated and requires some form of treatment. Since the juvenile spine still has growth potential, it is inevitable that the lateral convexity will progress in theory. However, the study by Mannherz et al. found that the left chest bend or the left lumbar bend is most likely to subside. This also suggests that some of the juvenile 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 around 20°, the ratio of male to female is basically equal; in the crowd of scoliosis greater than 20°, female: male exceeds 5:1. The fact that women with scoliosis are more severe suggests that female scoliosis may be more progressive and that 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°, the forced vital capacity usually drops to 70% to 80% of the expected value. Decreased lung function is usually secondary to restrictive lung disease. If severe scoliosis impairs lung function, the patient may die of pulmonary heart disease in the early stage. According to some scholars, the mortality rate of patients with severe scoliosis is twice that of the general population, and the risk of death in smoking patients is increased. The incidence of intermittent back pain in patients with moderate scoliosis (40° to 50°) is approximately the same as in the general population. The incidence of severe lumbar scoliosis is high, and the incidence of apical vertebrae is significantly higher. .
It is precisely because scoliosis can cause the above complications, so early active treatment should be taken to prevent the progression of scoliosis. As early as the 20th to 20th centuries of the 20th century, young patients diagnosed with scoliosis would immediately undergo brace treatment because many doctors thought that scoliosis was in progress in the growing season, and the brace could stop Its development can even improve the size of the side bends. Since then, orthopedic surgeons have gradually deepened their understanding of the progress of scoliosis and non-surgical treatment.
Lonstein and Carlson studied the relationship between the degree of scoliosis and the risk of Risser's sign, age and scoliosis. The convexity of the scoliosis was between 20° and 30°. Studies have confirmed that the degree of scoliosis is associated with the above three, and most scoliosis is stable without treatment. Their study showed that if a 12-year-old patient had Risser's sign of 0 degrees or 1 degree, the right thoracic convexity, and the Cobb angle of 20° to 29°, the average risk of scoliosis progression was 68%.
At present, some scholars believe that the scoliosis does not progress in mature patients. WeinStein and Ascani analyzed risk factors for AIS progression in adults. They confirmed that nearly mature patients with a thoracic scoliosis less than 40° rarely progressed after adulthood, while those with greater than 40° (especially >50°) thoracic scoliosis progressed after maturity. In general, adult scoliosis progression is difficult to detect and usually progresses at a rate of 1° or 2° per year. For example, an 18-year-old matured patient currently has a thoracic scoliosis with a curvature of 55°. It can be developed to 100° by the time the patient is 50 years old.
In short, most scholars believe that: First, not all scoliosis progresses, and not all scoliosis needs treatment; second, when the patient is mature, his scoliosis does not necessarily stop progressing.
Early diagnosis and early treatment of scoliosis are essential. Therefore, it is necessary to improve the census work of primary and secondary school students and to achieve prevention.
1. History of scoliosis: Ask in detail about all conditions related to spinal deformity, such as the patient's health, age and sexual maturity. Also need to pay attention to past history, surgical history and trauma history. It is necessary to understand the health status of the mother of the spine deformity during pregnancy, whether there is a history of medication during the first 3 months of pregnancy, and whether there are complications during pregnancy or childbirth. Family history should pay attention to the situation of other people with spinal deformity. Family history is particularly important in neuromuscular scoliosis.
2. Physical examination of scoliosis: pay 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, with or without coffee spots and subcutaneous tissue, and with long hair on the back and cystic material. Pay attention to the development of the breast, whether the thorax is symmetrical, with or 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 rotation and produces a typical paravertebral rib hump. The rotation of the torso, the vertebral ribs and the bulging of the lateral paravertebral muscles are visible deformities of the scoliosis. The Adam flexion test is often used to screen for paravertebral deformities of scoliosis. The method is as follows: the patient faces the examiner, and the patient bends forward until the trunk is parallel to the horizontal plane to see if the back is symmetrical. One side of the ridge indicates the rib and vertebral rotation deformity. . A certain amount of experience is required to determine the apparent paravertebral rotation. Bunnell has designed a scoliosis measuring ruler to improve its accuracy. The measuring ruler is placed on the scoliosis of the scoliosis. The angle of trunk rotation (ATR), the angle of rotation of the trunk and the spine can be measured. The severity of the scoliosis is related, and many spine surgeons suggest that there is a torso rotation if the ATR is greater than 5°. At the same time, it is necessary to measure the distance between the rib angles on both sides and the tibia. 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 is measured to indicate the degree of deformity.
Then, check the range of motion of the flexion, overextension, and lateral curvature of the spine. Check the flexibility of each joint, such as the proximity of the wrist and thumb, the overextension of the fingers, the flexion of the knees and elbow joints, etc.
Finally, the nervous system should be carefully examined, especially in the lower limbs. It should be confirmed whether there is damage to the nervous system. If the patient has significant muscle weakness, it is necessary to look for potential neurological abnormalities. Not all patients with neurological damage have obvious signs, which may be only minor signs, such as abdominal wall reflex asymmetry, slight clonic or extensive Muscle weakness. However, these signs suggest that the nervous system should be examined in detail, and the authors recommend MRI to scan the entire spinal cord. With the application and popularity of MRI and other tests, the authors have been able to diagnose central nervous system malformations that were previously difficult to detect, such as hydromyelia and tethered cord. Most of the hydrocephalus is left-sided, so MRI is recommended for all patients with scoliosis on the left side. For each patient, the possibility of central nervous system disease should be considered.
For those suspected of having mucopolysaccharidosis, attention should be paid to the cornea. Patients with Ma Fang syndrome should pay attention to their upper jaw.
The patient's height, weight, distance between the arms, and the length and feel of both lower limbs should be recorded.
Infantile idiopathic scoliosis: Infant scoliosis needs to be differentiated from congenital scoliosis, neuromuscular scoliosis, and scoliosis secondary to intraspinal lesions. Therefore, a detailed physical examination must be performed and the presence of oblique head deformities and limb deformities should be recorded.
At the first visit, the full-length and lateral X-ray films of the spine should be taken. The Cobb angle and rib-vertebral angle difference (RVAD) should be evaluated first, and the congenital vertebral deformity should be excluded. Before the baby can stand, the full-length positive image examination of the supine spine can be used to find out whether there is fusion and instability of the cervical vertebra, and whether there are congenital malformations and hip dysplasia in the lumbosacral region and hip.
Most babies diagnosed with scoliosis have subtle neurological symptoms that can prompt us for 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 infantile scoliosis is rare, and due to the high incidence of neurological malformations and the need for treatment, full spine MRI should be routinely performed even if the patient's neurological physical examination is normal in this age group. an examination. MRI examination of the brain and spinal cord should be performed for all infants requiring active treatment. Gupta et al. and Lewonowski et al found that patients with normal scoliosis in the neurological examination 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 a regressive infant type. 2 benign progressive infant type. 3 symptomatic scoliosis. 4 sinus cavity scoliosis. 5 early found in adolescents.
Before definitive diagnosis, the cause of the scoliosis must be ascertained. The nervous system should be carefully examined, and sometimes the disappearance of abdominal wall reflexes is the only clue to the diagnosis of Chiari malformation. Although most neurological examinations in children with IS are normal, due to the relatively high incidence of intraspinal lesions, some scholars recommend routine MRI for all children with scoliosis. Gupta's study found that the incidence of axonal deformity in asymptomatic children with idiopathic scoliosis was 18% to 20%. At this age, scoliosis may be one of the first signs of a potential nerve axis malformation.
Continuous Cobb angle measurements can determine if the scoliation is progressing. Factors associated with progression of the juvenile IS scoliosis include an increase in the RVAD of the main vertebrae, a chest kyphosis of less than 20°, and a boy's left vertebral curvature. Kahanovitz et al. believe that 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 and lateral: the upright position of the full spine is the most basic means of diagnosis. X-ray images need to include the entire spine. The X-ray film must emphasize the upright position and not the lying position. If the patient is not standing upright, it is advisable to use a sitting position to reflect the true condition of scoliosis.
(2) Bending of the spine: The bending of the spine includes the supine position and the supine position. It is currently used in the supine position. It is mainly used 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 cooperation of patients, and its influencing factors are more, the age and education level of patients are all 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 traction image: A. can provide a full view of the scoliosis traction reset. 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) Bending point 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 operational requirements are: 1 full lateral position. 2 Select a cylinder of suitable size (cylinder diameters of 14 cm, 17 cm, 21 cm, respectively) to separate the shoulder from the bed surface.
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. The lumbosacral oblique image is used for patients with spondylolisthesis and isthmic fissure.
(6) Ferguson image: The Ferguson image is used to check the joint of the lumbosacral joint. In order to eliminate lumbar lordosis, the male tube is tilted 30° to the head side and the woman 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 processes and vertebral deformities . It is necessary to take a rotating image to get a true front and rear image. Rotate the patient under fluoroscopy, and take the film when the maximum camber occurs. The film is parallel to the inner side of the rib bulge, and the tube is perpendicular to the piece.
(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. 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 findings of pedicle distance widening, spinal canal regurgitation, 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 examinations: helpful for patients with spinal cord disease. Such as spinal cord fissure, syringomyelia and so on. Understanding the plane and extent of the epiphysis is important for orthopedics, resection of the epiphysis, and prevention of paraplegia, but it is expensive and should not be routinely examined.
4. X-ray measurement of scoliosis
(1) The main points of X-ray film reading: 1 end vertebra: the vertebral body at the head end and the end end of the curvature of the scoliosis. 2 vertebral vertebrae: the vertebral body with the most severe deformity and the farthest deviation 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 bends, the middle bend is often the main side bend, and when there are 4 bends, the middle two are double main bends.
(2) Measurement of scoliosis of the scoliosis: 1 Cobb method: Most commonly used, the angle between the perpendicular line of the upper edge of the cephalad and the vertical line of the lower edge of the caudal end is the Cobb angle. If the upper and lower edges of the end vertebrae are unclear, the line connecting the upper and lower edges of the pedicle can be taken, and then the angle of intersection of the perpendicular lines is the Cobb angle. 2Ferguson method: rarely used, sometimes used to measure mild side bends. Find the midpoint of the end vertebrae and the vertebral body. Then draw two lines from the midpoint of the apical vertebra to the midpoint of the upper and lower vertebrae. The angle of intersection is the side 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: posterior apical vertebrae, upper end vertebrae, apical vertebrae, and sacral centerline (CSVL).
5. Identification of scoliosis maturity The evaluation of maturity is particularly important in the treatment of scoliosis. It must be comprehensively assessed based on physiological age, actual age and bone age, including the following:
(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 20 years old, 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 degrees, and the upper spine is IV degrees after moving to the iliac crest. The epiphysis and the tibia are fused to V degrees. 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: routine examination of blood routine, urine routine, creatinine, urea nitrogen, blood sugar, etc. before surgery.
7. 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, vital capacity, and residual capacity. 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, 40% to 60% is moderately restricted, and less than 40% is severely restricted.
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, unless it is advanced. The reduction in lung capacity is related to the severity of the scoliosis.
Diagnosis
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 detect structural deformities in the spine. Basic malformations can be divided into three types: 1, spinal deformity, such as semi-vertebral body; 2, poor spine segmentation, such as unilateral unsectioned bone bridge; 3, mixed type. If the conventional X-ray film is difficult to identify, CT can be used.
(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. The latter includes muscular dystrophy, spinal muscular atrophy and the like. The pathogenesis of this kind of scoliosis is caused by the loss of the nervous system and muscles to control the regulation of the balance of the spine. The cause of the disease often needs careful clinical examination to detect, sometimes it requires nerve-electromyography or nerve-muscle biopsy. To be able 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. Diagnosis can be made when the clinical compliance with the following two or more criteria. 1. Patients before maturity have more than 6 skin coffee spots with a diameter of more than 5 mm or more than 15 mm in diameter after maturity; 2. Two or more forms of neurofibroma or plexus plexus neurofibroma; Skin freckle in the axillary or inguinal region; 4, optic glioma; 5, more than two scleral hamartomas (Lisch nodules); 6, bone lesions, such as long cortical thinning; 7, family history. The X-ray features of the scoliosis associated with the patient can be similar to idiopathic scoliosis, or can be expressed as "dystrophic" scoliosis, that is, the angulated type of posterior process of the short segment, the spine is severe Rotation, vertebral body depression, etc., such scoliosis continues to progress, 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.
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 less than 1% in patients with idiopathic scoliosis. Early diagnosis of infantile idiopathic scoliosis is important, and parents and pediatricians should closely observe this. Because early treatment can affect the prognosis, it 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 cases of natural disease, and according to this, it is divided into two types: self-limiting and progressive. A large number of studies have confirmed that the characteristics of infantile 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 chest 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 deformity, congenital torticollis, and progressive hip development). Bad, etc.).
2. Juvenile idiopathic scoliosis: juvenile idiopathic scoliosis is a scoliosis deformity found between 4 and 10 years old, which accounts for 12% of idiopathic scoliosis~ 21%, the cause is unknown.
Characteristics: Compared with infantile and adolescent idiopathic scoliosis, juvenile idiopathic scoliosis is characterized by a relatively quiescent progression of spinal growth. Scholars know little about its type of scoliosis and natural history. It is only diagnosed by finding the age of the deformity rather than by symptoms and signs. Therefore, how to diagnose the juvenile idiopathic scoliosis has become the focus of discussion. Patients diagnosed with a juvenile type are likely to have advanced onset infantile idiopathic scoliosis or early onset adolescent idiopathic scoliosis that 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. The ratio of female to male is about 1:1 for children aged 3 to 6 years. 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 chest bend accounts for 2/3 of the youth type IS, the double main bend accounts for about 20%, and the thoracolumbar scoliosis accounts for 15%. The left chest curve is not common in the juvenile type. 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 juvenile type is more invasive, and it can progress to severe deformity and impair lung function. Approximately 70% of juvenile idiopathic scoliosis is progressively exacerbated and requires some form of treatment. Since the juvenile spine still has growth potential, it is inevitable that the lateral convexity will progress in theory. However, the study by Mannherz et al. found that the left chest bend or the left lumbar bend is most likely to subside. This also suggests that some of the juvenile 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 around 20°, the ratio of male to female is basically equal; in the crowd of scoliosis greater than 20°, female: male exceeds 5:1. The fact that women with scoliosis are more severe suggests that female scoliosis may be more progressive and that 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°, the forced vital capacity usually drops to 70% to 80% of the expected value. Decreased lung function is usually secondary to restrictive lung disease. If severe scoliosis impairs lung function, the patient may die of pulmonary heart disease in the early stage. According to some scholars, the mortality rate of patients with severe scoliosis is twice that of the general population, and the risk of death in smoking patients is increased. The incidence of intermittent back pain in patients with moderate scoliosis (40° to 50°) is approximately the same as in the general population. The incidence of severe lumbar scoliosis is high, and the incidence of apical vertebrae is significantly higher. .
It is precisely because scoliosis can cause the above complications, so early active treatment should be taken to prevent the progression of scoliosis. As early as the 20th to 20th centuries of the 20th century, young patients diagnosed with scoliosis would immediately undergo brace treatment because many doctors thought that scoliosis was in progress in the growing season, and the brace could stop Its development can even improve the size of the side bends. Since then, orthopedic surgeons have gradually deepened their understanding of the progress of scoliosis and non-surgical treatment.
Lonstein and Carlson studied the relationship between the degree of scoliosis and the risk of Risser's sign, age and scoliosis. The convexity of the scoliosis was between 20° and 30°. Studies have confirmed that the degree of scoliosis is associated with the above three, and most scoliosis is stable without treatment. Their study showed that if a 12-year-old patient had Risser's sign of 0 degrees or 1 degree, the right thoracic convexity, and the Cobb angle of 20° to 29°, the average risk of scoliosis progression was 68%.
At present, some scholars believe that the scoliosis does not progress in mature patients. WeinStein and Ascani analyzed risk factors for AIS progression in adults (Table 3). They confirmed that nearly mature patients with a thoracic scoliosis less than 40° rarely progressed after adulthood, while those with greater than 40° (especially >50°) thoracic scoliosis progressed after maturity. In general, adult scoliosis progression is difficult to detect and usually progresses at a rate of 1° or 2° per year. For example, an 18-year-old matured patient currently has a thoracic scoliosis with a curvature of 55°. It can be developed to 100° by the time the patient is 50 years old.
In short, most scholars believe that: First, not all scoliosis progresses, and not all scoliosis needs treatment; second, when the patient is mature, his scoliosis does not necessarily stop progressing.
Early diagnosis and early treatment of scoliosis are essential. Therefore, it is necessary to improve the census work of primary and secondary school students and to achieve prevention.
1. History of scoliosis: Ask in detail about all conditions related to spinal deformity, such as the patient's health, age and sexual maturity. Also need to pay attention to past history, surgical history and trauma history. It is necessary to understand the health status of the mother of the spine deformity during pregnancy, whether there is a history of medication during the first 3 months of pregnancy, and whether there are complications during pregnancy or childbirth. Family history should pay attention to the situation of other people with spinal deformity. Family history is particularly important in neuromuscular scoliosis.
2. Physical examination of scoliosis: pay 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, with or without coffee spots and subcutaneous tissue, and with long hair on the back and cystic material. Pay attention to the development of the breast, whether the thorax is symmetrical, with or 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 rotation and produces a typical paravertebral rib hump. The rotation of the torso, the vertebral ribs and the bulging of the lateral paravertebral muscles are visible deformities of the scoliosis. The Adam flexion test is often used to screen for paravertebral deformities of scoliosis. The method is as follows: the patient faces the examiner, and the patient bends forward until the trunk is parallel to the horizontal plane to see if the back is symmetrical. One side of the ridge indicates the rib and vertebral rotation deformity. . A certain amount of experience is required to determine the apparent paravertebral rotation. Bunnell has designed a scoliosis measuring ruler to improve its accuracy. The measuring ruler is placed on the scoliosis of the scoliosis. The angle of trunk rotation (ATR), the angle of rotation of the trunk and the spine can be measured. The severity of the scoliosis is related, and many spine surgeons suggest that there is a torso rotation if the ATR is greater than 5°. At the same time, it is necessary to measure the distance between the rib angles on both sides and the tibia. 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 is measured to indicate the degree of deformity.
Then, check the range of motion of the flexion, overextension, and lateral curvature of the spine. Check the flexibility of each joint, such as the proximity of the wrist and thumb, the overextension of the fingers, the flexion of the knees and elbow joints, etc.
Finally, the nervous system should be carefully examined, especially in the lower limbs. It should be confirmed whether there is damage to the nervous system. If the patient has significant muscle weakness, it is necessary to look for potential neurological abnormalities. Not all patients with neurological damage have obvious signs, which may be only minor signs, such as abdominal wall reflex asymmetry, slight clonic or extensive Muscle weakness. However, these signs suggest that the nervous system should be examined in detail, and the authors recommend MRI to scan the entire spinal cord. With the application and popularity of MRI and other tests, the authors have been able to diagnose central nervous system malformations that were previously difficult to detect, such as hydromyelia and tethered cord. Most of the hydrocephalus is left-sided, so MRI is recommended for all patients with scoliosis on the left side. For each patient, the possibility of central nervous system disease should be considered.
For those suspected of having mucopolysaccharidosis, attention should be paid to the cornea. Patients with Ma Fang syndrome should pay attention to their upper jaw.
The patient's height, weight, distance between the arms, and the length and feel of both lower limbs should be recorded.
Infantile idiopathic scoliosis: Infant scoliosis needs to be differentiated from congenital scoliosis, neuromuscular scoliosis, and scoliosis secondary to intraspinal lesions. Therefore, a detailed physical examination must be performed and the presence of oblique head deformities and limb deformities should be recorded.
At the first visit, the full-length and lateral X-ray films of the spine should be taken. The Cobb angle and rib-vertebral angle difference (RVAD) should be evaluated first, and the congenital vertebral deformity should be excluded. Before the baby can stand, the full-length positive image examination of the supine spine can be used to find out whether there is fusion and instability of the cervical vertebra, and whether there are congenital malformations and hip dysplasia in the lumbosacral region and hip.
Most babies diagnosed with scoliosis have subtle neurological symptoms that can prompt us for 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 infantile scoliosis is rare, and due to the high incidence of neurological malformations and the need for treatment, full spine MRI should be routinely performed even if the patient's neurological physical examination is normal in this age group. an examination. MRI examination of the brain and spinal cord should be performed for all infants requiring active treatment. Gupta et al. and Lewonowski et al found that patients with normal scoliosis in the neurological examination 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 a regressive infant type. 2 benign progressive infant type. 3 symptomatic scoliosis. 4 sinus cavity scoliosis. 5 early found in adolescents.
Before definitive diagnosis, the cause of the scoliosis must be ascertained. The nervous system should be carefully examined, and sometimes the disappearance of abdominal wall reflexes is the only clue to the diagnosis of Chiari malformation. Although most neurological examinations in children with IS are normal, due to the relatively high incidence of intraspinal lesions, some scholars recommend routine MRI for all children with scoliosis. Gupta's study found that the incidence of axonal deformity in asymptomatic children with idiopathic scoliosis was 18% to 20%. At this age, scoliosis may be one of the first signs of a potential nerve axis malformation.
Continuous Cobb angle measurements can determine if the scoliation is progressing. Factors associated with progression of the juvenile IS scoliosis include an increase in the RVAD of the main vertebrae, a chest kyphosis of less than 20°, and a boy's left vertebral curvature. Kahanovitz et al. believe that 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 and lateral: the upright position of the full spine is the most basic means of diagnosis. X-ray images need to include the entire spine. The X-ray film must emphasize the upright position and not the lying position. If the patient is not standing upright, it is advisable to use a sitting position to reflect the true condition of scoliosis.
(2) Bending of the spine: The bending of the spine includes the supine position and the supine position. It is currently used in the supine position. It is mainly used 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 cooperation of patients, and its influencing factors are more, the age and education level of patients are all 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 traction image: A. can provide a full view of the scoliosis traction reset. 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) Bending point 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 operational requirements are: 1 full lateral position. 2 Select a cylinder of suitable size (cylinder diameters of 14 cm, 17 cm, 21 cm, respectively) to separate the shoulder from the bed surface.
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. The lumbosacral oblique image is used for patients with spondylolisthesis and isthmic fissure.
(6) Ferguson image: The Ferguson image is used to check the joint of the lumbosacral joint. In order to eliminate lumbar lordosis, the male tube is tilted 30° to the head side and the woman 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 processes and vertebral deformities . It is necessary to take a rotating image to get a true front and rear image. Rotate the patient under fluoroscopy, and take the film when the maximum camber occurs. The film is parallel to the inner side of the rib bulge, and the tube is perpendicular to the piece.
(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. 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 findings of pedicle distance widening, spinal canal regurgitation, 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 examinations: helpful for patients with spinal cord disease. Such as spinal cord fissure, syringomyelia and so on. Understanding the plane and extent of the epiphysis is important for orthopedics, resection of the epiphysis, and prevention of paraplegia, but it is expensive and should not be routinely examined.
4. X-ray measurement of scoliosis
(1) The main points of X-ray film reading: 1 end vertebra: the vertebral body at the head end and the end end of the curvature of the scoliosis. 2 vertebral vertebrae: the vertebral body with the most severe deformity and the farthest deviation 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 bends, the middle bend is often the main side bend, and when there are 4 bends, the middle two are double main bends.
(2) Measurement of scoliosis of the scoliosis: 1 Cobb method: Most commonly used, the angle between the perpendicular line of the upper edge of the cephalad and the vertical line of the lower edge of the caudal end is the Cobb angle. If the upper and lower edges of the end vertebrae are unclear, the line connecting the upper and lower edges of the pedicle can be taken, and then the angle of intersection of the perpendicular lines is the Cobb angle. 2Ferguson method: rarely used, sometimes used to measure mild side bends. Find the midpoint of the end vertebrae and the vertebral body. Then draw two lines from the midpoint of the apical vertebra to the midpoint of the upper and lower vertebrae. The angle of intersection is the side 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: posterior apical vertebrae, upper end vertebrae, apical vertebrae, and sacral centerline (CSVL).
5. Identification of scoliosis maturity The evaluation of maturity is particularly important in the treatment of scoliosis. It must be comprehensively assessed based on physiological age, actual age and bone age, including the following:
(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 20 years old, 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 (Fig. 7). The ossification moves from the anterior superior iliac spine to the posterior superior iliac spine. The epiphysis moves 25% to I degree, 50% II degree, 75% is III degree, and the upper spine is IV degree after moving to the iliac crest. The epiphysis and the tibia are fused to V degrees. 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 examination 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, vital capacity, and residual capacity. 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, 40% to 60% is moderately restricted, and less than 40% is severely restricted.
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, unless it is advanced. The reduction in lung capacity is related to the severity of the scoliosis. Breakline
