SCOLIOSIS (Greek. skoliosis curvature) — a rachiocampsis in the frontal plane. The term is entered by K. Galen.
The page is observed at many diseases, being in the majority случаев^ one of their manifestations.
On a pathogenetic sign allocate discogenic, gravitational and miotic S.
Diskogenny S. develops because of a dysplastic syndrome. Disturbances of exchange in connecting fabric at the same time lead to structural change of a backbone owing to what communication of an intervertebral disk with bodies of vertebrae at top of future curvature and shift of a disk weakens. Together with them it is displaced jellylike (bullets - postural) the kernel, a cut now is located not in the center, as usual, and closer to the convex party of a curvature. It, in turn, causes primary inclination of vertebrae that causes development of the mechanisms counterbalancing a backbone: a muscle tension of a trunk and sheaves, a cut
S. Osnova of gravitational S. — a contracture of muscles, extensive and rough hems on a trunk, a distortion of a basin, etc. leads to development of secondary curvatures and formation. The proximate cause leading to deformation is the shift of the center of gravity and action of body weight away from a longitudinal axis of a backbone.
Miotic S. arises because of poliomyelitis, a myopathy and other diseases resulting in functional insolvency of muscles of a trunk.
On morfol. S.'s signs can divide on structural and nonstructural. Understand S. as structural, at Krom there are structural changes of the vertebrae entering an arch of a curvature including a wedge-shaped shape of bodies of vertebrae, their torsion (twisting). Carry various functional states to nonstructural S., napr, a scoliotic bearing, an antalgi-chesky pose at radiculitis (so-called reflexo-painful S.), etc. These types of S. were named professional, school, senile, functional S. earlier; in a crust, time these terms are not applied.
Structural S. is divided into so-called idiopathic scoliosis; neurogenic — at patients with poliomyelitis, spastic paralysis (spastic S.), tumors of a spinal cord, a myelosyringosis, etc.; myogenetic — at patients with a muscular atrophy, arthrogryposis (see), etc. inborn S. because of a neurofibromatosis; Page, connected with mesenchymal disturbances, napr, at Marfan's disease; Page at collagenic diseases; traumatic S. at fractures of vertebras, after a laminectomy, because of cicatricial changes in a pleura or hems on skin after burns (cicatricial S.); Page owing to dystrophic changes of a cartilage and bone tissue; Page because of rickets; Page at inf. diseases of a backbone (spondylites); Page at tumors of a backbone; Page as a result of an abnormal structure of lumbar vertebrae and their joints (a spondylosis and a spondylolisthesis, anomalies of joint shoots).
The idiopathic S. making about 90% of all cases of S. V its cornerstone is of the greatest practical interest disturbances of exchange are connecting fabric. Depending on age, in Krom there was a deformation of a backbone, idiopathic S. is subdivided on infantile (aged up to 3 years), children's (aged from 3 up to 10 years) and teenage (10 years are aged more senior).
On localization of top of a curvature, according to the classification extended in a crust, time offered by Ponsetti and Friedman (J. V. Ponsetti, V. of J. Friedman), S. divide on verkhnegrudny — the top of a curvature is located at the level of Thm_VI (makes 1,3 — 3,6% of all types C.), chest — the top of a curvature is located at the level of ThVIII_IX (according to various data, makes 21,7 — 42,9% of all types C.), grudopoyasnichny — the top of a curvature, as a rule, is located at the level of ThXI — Lr (U-2014\of 24,7% of cases meets in 15,8 \), lumbar — the top of a curvature is located at the level of Ln (8,8 — 24% of cases of S.). Besides, allocate the so-called combined S. with two primary curvatures: chest (top of a curvature at the level of ThVIII_IX) and lumbar (top of a curvature at the level of Ln). It is quite widespread type C., frequency to-rogo makes from 16,7 to 37% of cases of Page. In a form of a curvature distinguish With - and S-shaped S.
the Clinical picture
the Factor defining a wedge, a picture C. is the size of a curvature. In the USSR (1958) four-sedate system of assessment of size of a rachiocampsis offered by V. D. Chaplin are applied. On this system to the I degree carry curvatures from 5 to 10 °, to the II degree — curvatures from 11 to 30 °, to the III degree — from 31 to 60 ° and to the IV degree — from 61 to 90 ° and more.
At an early stage of S. it is shown by primary inclination of vertebrae at top of future main curvature which is followed by secondary curvatures, to-rye at this moment have functional character and come to light standing only on the roentgenograms made in position of the patient; in pictures in a prone position they disappear. At further development of S. the inclination of pozvonl in the field of top of a curvature forms already real arch, and secondary curvatures gradually lose the functional character. During this period the expressed asymmetry of intervertebral disks at a symmetric shape of bodies of vertebrae is noted, but the last are already a little turned in the convex party. In this process at first the functional component — the rotation of vertebrae replaced then a structural component — torsion, or twisting, vertebrae prevails, at a cut not only the form (the body of a vertebra is displaced rather back half ring towards a curvature), but also structure of a vertebra is broken. In particular, bone crossbeams of a spongy bone unlike the normal vertical and horizontal direction get a spiral arrangement. With the advent of primary inclination muscles of a trunk begin to take part in formation of deformation, to-rye not only counteract an inclination, but also cause development of secondary curvatures. At the earliest stages of development of deformation jellylike kernels at top of the main curvature are displaced in the convex party, at the same time in secondary curvatures they appear on the usual place. At further development of deformation of a body of vertebrae get a wedge-shaped form at top of a curvature that already considerably complicates correction of deformation. Expressiveness of structural changes depends not so much on the size of deformation how many from time of its existence.
The rachiocampsis causes a number of changes in other bodies and first of all deformation thorax (see). At the same time edges are deformed in the beginning — on the convex party of a rachiocampsis they form a so-called costal hump, and on the concave party back departments of edges are flattened. In this regard the volume of a thorax decreases, the mechanism of its respiratory movements is broken. These changes in a skeleton are followed by dysfunctions of lungs and cardiovascular system. In lungs appear atelectases (see), alternating with emphysematous sites. Against the background of these changes pressure in a small circle of blood circulation increases, a cut eventually leads to development of so-called kifoskoliotichesky heart. At heavy S. these changes can cause development of heart and respiratory failure (see. Respiratory insufficiency , Heart failure ), as a rule, against the background of various respiratory diseases.
Deformation of a backbone changes normal ratios of a trunk of the patient. At survey asymmetry of the triangles of a waist formed by the lowered hands and a waist is noted. Asymmetric situation over-plechy, a deviation of a trunk in one party in relation to a basin can be observed, at different height nipples of mammary glands are located, the navel is located not on the centerline of a body. At survey from a back the rachiocampsis and in the sagittal plane can be revealed. The expressed kyphosis in chest department — a kyphoscoliosis is most often noted (see. Kyphosis ), the lordosis — a lordoscoliosis meets less often (see the Lordosis). Data of survey can be objektivizirovana by measurement or photometry. For this purpose apply projections of tops of acanthas, corners of shovels, ileal crests on a body of the patient with a special pencil, and photograph the patient through a special grid with the known size of cells.
At the compensated S. the plumb lowered from top of a curvature passes on a mezhjyagodichny fold, at dekompensirovanny S. — is displaced towards a curvature. The rachiocampsis at S. includes the main curvature and two secondary. At the combined type of a curvature there are two the main curvature. Task wedge, and rentgenol. inspections first of all definition of the main curvature and, therefore, type C is. For the solution of this question the following criteria are used: 1) the main curvature, as a rule, is more than secondary; 2) the index of stability of the main curvature is always higher, than on secondary; 3) from three krivizn average always is the main; 4) at dekompensirovanny S. the trunk of the patient is rejected towards top of the main curvature. Torsion and wedge-shaped deformation of vertebrae in the field of top of a curvature on the main curvature is expressed usually more, than on secondary.
Rentgenol. the research allows to reveal the forms C. which are not defined clinically, its level, to precisely measure the size of a curvature that allows to designate its degree, to establish secondary dystrophic changes in vertebrae and intervertebral disks, to carry out differential diagnosis with other diseases backbone (see) to control efficiency of treatment, to estimate a condition and interposition of bodies of a thorax and abdominal cavity that is especially important at big curvatures.
At the expressed S. the X-ray analysis in a direct projection (fig.) is most informative. At small curvatures the X-ray analysis in a side projection does not lose the value (it should be seen off on that party, in to-ruyu the top of a curvature is turned).
For definition of stability of deformation calculate an index of stability by a formula J St = B/B 1 , where In and In 1 — the angles of deformation in a standing position and lying. The type C., degree of a curvature, an index of stability define at a radiographic research of a backbone. Calculation of size of deformation is made by means of methods of Kobba or Ferguson (see. Skoliozometriya ).
Insignificant rachiocampsis most often for the first time comes to light at rentgenol. a research since owing to rotation of vertebrae the line going on acanthas is bent always less, than the line of an arrangement of bodies of vertebrae. A side rachiocampsis measures on a corner of its bend on the roentgenogram executed in a direct projection. At S. on roentgenograms asymmetry of bodies of separate vertebrae is found. Than more sharply it is expressed and more vertebrae are involved in process, especially S. Obychno is expressed the asymmetric growth of a body of a vertebra is followed by turn of all vertebra with an arch and shoots. In an initial stage of development of S. in children it is difficult to catch asymmetry of height of the right and left half of a body of a vertebra. Therefore practically the most precursory symptom of the developing S. indicating growth disorder of separate vertebrae is their rotation which is easily determined on the roentgenogram in a direct projection by the shift of images of legs of arches and an acantha concerning a body of a vertebra.
Indirect value in idiopathic S.'s diagnosis can have identification of displaziya of other localizations, first of all a backbone — an union or a nezara-shcheniye of arches and shoots, the bone block of two or several vertebrae, lack of one half of a body or an arch of a vertebra, spina bifida in lumbar or sacral departments (see. Spina bifida ), sacralization (see) or lumbalization (see), especially asymmetric, etc. As all dysplastic deformations of a skeleton (both inborn, and acquired) most intensively accrue during the periods of the accelerated growth of an organism, at this time it is necessary to carry out control rentgenol. researches with obligatory comparison of their results in to dynamics.
Rentgenol. the research allows to estimate also degree of an overload of intervertebral disks on concave side and rotation of vertebras around a long axis of a backbone, to reveal in them dystrophic changes, patol. shifts of bodies of vertebrae, joining osteochondrosis (see), shown regional bone growths and subchondral osteosclerosis (see), decrease in height of disks, ossification of the copular device with development spondylosis (see), development of the deforming arthrosis in dugootrostchaty joints — spondylarthrosis (see), emergence of zones of reorganization in the acanthas developing owing to strong side draft of sheaves at shifts of vertebrae (see. Loozera of a zone ).
Treatment depends on age of the patient, type C. and extent of deformation of a backbone. Infantile S. treat conservatively, stacking the child in the provision of correction in corrective beds from gypsum or thermoplastic material of a polivik, carry out also massage, passive gymnastics.
Children's S. at I and II degrees of a rachiocampsis treat also conservatively. An important condition of successful treatment are good and vitamin-rich nutrition, regular stay in the fresh air, outdoor games. The bed of the child shall be rigid for what stack a wooden board on a bed. The chair and a table in a workplace of the child shall correspond to his growth. It is necessary to watch that the child sat at a table directly, and legs it at the same time reached a floor. Also correct installation of light is important, and at the broken sight its correction is obligatory. Carry systematically out to lay down. to a pshnastik and often appoint carrying corsets of the Milwaukee type or TsNIIPP — CYTO (see. Orthoses ). Out-patient treatment of children's S. demands active participation of parents.
Conservative treatment is carried out also at special boarding schools for children from S., in to-rykh along with training in the usual program the necessary round-the-clock medical mode is created.
One of the leading means of conservative treatment of S. is physiotherapy exercises (see). Physical exercises exert the stabilizing impact on a backbone, strengthening muscles of a trunk, allow to achieve corrective impact on deformation, to improve a bearing, function of external respiration, give fortifying effect. For methodically correct use of LFK it is necessary to establish S.'s etiology, localization, the direction and degree of a rachiocampsis, and also character of a current patol. process.
LFK is shown at all stages of development of S., but it yields more successful results at initial forms C. The physical exercises increasing flexibility of a backbone and leading to its restretching are contraindicated. The complex of means of LFK applied at conservative treatment of S. includes to lay down. gymnastics (see. Gymnastics corrective ), exercises in water, massage (see), correction by situation, elements of sport; LFK is combined with the mode of a reduced static load on a backbone. LFK carry out in the form of group occupations, individual procedures (are preferential shown to patients at adverse disease), and also the individual tasks performed by patients independently.
The technique of LFK is defined first of all by a current of Page. At the compensated process (lack of signs of progressing) to lay down. the gymnastics is carried out usually with group of children, using different types of the physical exercises developing a correct posture, the corrective S. strengthening muscular system, etc. At S. with tendency to progressing of LFK it is desirable to carry out individually in position of the patient lying (on a back, a stomach, a side), using only the exercises which are intensively strengthening muscles of a back and a stomach. LFK combine with manual massage of muscles of a back and stomach and carrying the corset fixing a backbone.
The technique of LFK is defined also by S.'s degree: at scoliosis of I, III, IV degrees it is directed to increase in stability of a backbone (stabilization patol. process), while at scoliosis of the II degree — also on correction of deformation.
At inborn S. corrective exercises are contraindicated since they can lead to a decompensation. The fortifying exercises expanding a thorax, improving a bearing are used.
At the neurogenic S. caused by paralysis to lay down. the gymnastics is carried out in a prone position for the purpose of the differentiated strengthening of muscles (more often than a stomach).
S.'s correction during the performance of physical exercises is reached by change of provision of a shoulder, pelvic girdle and a trunk of the patient. Exercises shall be directed to correction of a rachiocampsis in the frontal plane and the available torsion of vertebrae. Carefully with tselyo corrections apply the exercises extending a backbone, napr at wall bars. Exercises to lay down. gymnastics shall serve strengthening of the basic muscular groups supporting a backbone — the muscles straightening a backbone, oblique muscles of a stomach, a square muscle of a waist, iliolumbar muscles, etc. From among the exercises promoting development of a correct posture exercises on balance, balancing, with strengthening of visual control, etc. are used.
Apply exercises to correction of a thorax, deforkhmirovanny at S., as it is symmetric the excursions of edges expanding it, and promoting improvement on the sunk-down party. Massage of muscles of a back and stomach is carried out more intensively and for a long time on the convex party of a curvature by methods of deep grinding, puddling, effleurage. It is shown to children of younger age and at the progressing disease. Elements of sport — swimming by style a breast stroke (after a preliminary course), walking on skis on the plain, elements of volleyball, are shown to children with the compensated S. Effekt's current, reached by use of physical exercises, fix by correction of situation, napr, laying of the patient sideways with the roller under a convex part of a rachiocampsis.
Practically in all cases of progressing of deformation carry out operational treatment not to allow development of heavy operational treatment of S. Osnova osteoplastic fixing of a backbone is: an exposure of acanthas and handles of vertebrae, removal of compact (cortical) substance from handles and fixing of vertebrae by means of transplants (see. Spondylodesis ). In a crust, time Harrington's method — fixing and correction of deformation of a backbone by means of the special metal distractors and counteractors applied together with osteoplastic fixing is eurysynusic. Also correction by means of the spring proofreader Grutsa (operation of GRU-tsy) is applied. In domestic orthopedics big distribution was gained by the corrective operations directed to mobilization of the deformed backbone. The diskotomiya — a section of intervertebral disks on the concave party belongs to such operations; enucleation, i.e. removal of jellylike kernels on the convex party of a curvature; a diskoepifizektomiya, at a cut excise intervertebral disks together with an epiphysis of bodies of vertebrae. At heavier curvatures apply different types of a wedge-shaped resection of bodies of vertebrae at top of a curvature. These operations combine with osteoplastic fixing of a backbone.
Success of operational treatment in many respects is defined by correctly carried out subsequent treatment, a cut includes an immobilization in a plaster bed during the first 10 days, carrying a high plaster corset (after correction of deformation by a diskotomiya). The immobilization in a plaster corset shall proceed during 1 year, and then in a removable corset with a headholder 1 more year.
The nature of surgery is defined by type C., extent of deformation of a backbone and age of patients. So, at chest S. of initial III degree first of all the diskotomiya is shown, to the developed III degree — enucleation of an intervertebral disk, and at the III—IV degree — a wedge-shaped resection.
At teenagers with a small potential of growth and at adult patients imposing of a distractor of Harrington is shown.
Chest S. with the expressed lumbar anticurvature demands two-stage operational treatment. At the first stage the lumbar curvature is corrected by means of Kazmin's distractors, and in 3 months after that make one of corrective operations on a chest curvature. The same tactics is shown also at kombiniro-vannokhm or S-shaped type C.
At lumbar S. first of all correction and fixing of a curvature by means of a distractor is shown, but at heavy Page IV of degree there can be a need for a wedge-shaped resection at top of a curvature.
Operational treatment of grudopoyasnichny S. is carried out also, as a rule, in two steps. Requires special attention verkhnegrudny S. as it is difficult to correct already developed deformation. At this type C. early operational treatment (a diskotomiya or enucleation) is necessary. The village, caused by any organic lesion of a backbone, spinal cord, muscles, demands first of all treatment of a basic disease. At the expressed deformations apply various corrective and stabilizing operations (see the Backbone).
The forecast depends on type of a curvature, its expressiveness and age of the patient. Infantile S.'s forecast is rather favorable. At timely diagnosis and the correct treatment it improves to 2 — to 3-year age. The page, remained and after this term, as a rule, leads further to heavy deformations. Children's S. predictively is less favorable, but in younger group self-healing is possible. At patients of teenage age the forecast is serious. In more senior age group conservative treatment is ineffective. More precisely the forecast can be established by means of various rentgenol. tests. E.g., Kohn's test (expansion of an intervertebral interval from the concave party of a curvature) can be revealed at children at the age of 4 — 8 years; it demonstrates progressing of deformation. Risser's test (condition of an epiphysis of an ileal bone) is based on J. I. P. James's data, to-ry considers that with the advent of a kernel of ossification of an epiphysis of an ileal bone progressing of deformation to 38 ° is possible, after end of ossification and with a body of an ileal bone deformation can increase to a spayaniye on 26 °, and after a spayaniye — to 18 °. Risser's test indicates only a possibility of progressing of S., but does not mean inevitability of the last. According to I. A. Movshovich, emergence in caudal departments of bodies of vertebrae on the convex party of osteoporosis demonstrates progressing of deformation (a so-called sign of Movshovich).
Prevention The page provides the prevention of a scoliotic bearing, timely treatment of the diseases which are followed by S.; concerning idiopathic S. — its timely treatment.
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A. I. Kazmin; P. L. Zharkov (rents.), A. F. Kaptelin (to lay down. physical.).