Scoliosis diagnosis

Scoliosis diagnostics begins with collecting anamnesis. It is necessary to find out at what age and by whom scoliosis was first diagnosed, whether the patient's parents consulted a doctor, what treatment for scoliosis was performed and what was its effect. It is extremely important to familiarize yourself with the patient's medical documentation, especially in cases where there are indications of previous surgical treatment of scoliosis. It is necessary to find out what the dynamics of the progression of the deformation was, with what age the peaks of this progression coincided. It is necessary to inquire about the state of the functions of the pelvic organs. Finally, since the overwhelming majority of patients with spinal deformities are girls, it is necessary to clarify at what age menstruation began (if this has already happened) and whether a normal menstrual cycle has been established.

The next stage is to find out the patient's complaints. There are usually two main complaints: a cosmetic defect associated with the deformation of the spine and chest. and back pain. It should be taken into account that the patient's assessment of his or her appearance is extremely variable. A relatively small scoliosis (40-45 according to Cobb) can cause severe moral suffering to a young patient. At the same time, patients with scoliosis of 75-80 often believe that their appearance is quite acceptable and does not need any correction. The situation with pain syndrome can be approximately the same. Often, a teenager does not focus on it and only upon targeted questioning specifies that his or her back hurts. It is necessary to find out whether the patient is bothered by shortness of breath, when it appeared, under what loads and whether it increases over the years.

The examination of the patient by an orthopedist is one of the most important elements of the examination. It must be carried out with the utmost care and properly documented. An integral and most important part of the clinical examination is the examination of the patient by a neurologist. The orthopedist and neurologist must work in constant contact, especially if the patient's condition is ambiguous.

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X-ray diagnostics of scoliosis

Survey radiography includes spondylography of the thoracic and lumbar spine (from Th1 to SI) in two standard projections with the patient standing. Spondylograms performed in the lying position are uninformative.

Functional radiography

When planning a surgical intervention, information is needed regarding the mobility of individual vertebral segments. Radiography with lateral torso tilts is performed in the supine position. The patient performs tilts actively, towards the convexity of the main and compensatory arches separately.

The second option for studying the mobility of the spine in scoliosis is traction spondylograms (in a standing or lying position). Spondylograms of the lumbar spine in the flexion and extension position are performed to clarify the condition of the lumbar intervertebral discs when planning the length of the spondylodesis zone in a patient with scoliosis.

Radiograph analysis

X-ray examination makes it possible to assess spinal deformity based on many parameters.

First of all, we are talking about the etiology. The presence of congenital anomalies of the vertebrae (wedge-shaped vertebrae and hemivertebrae, segmentation disorders) and ribs (synostoses, underdevelopment) indicates the congenital nature of the deformation. A short, rough arc makes one think of neurofibromatosis, and an extended, flat arc of neuromuscular etiology of scoliosis. In turn, the absence of these and other changes indicates that scoliosis is most likely idiopathic. Next, the type of scoliotic deformation is determined by the localization of its apex, the side of the convexity, the borders, and measurements are taken to characterize the deformation from a quantitative point of view.

Scoliosis is a three-dimensional deformation of the spine, so the study is carried out in three planes.

Frontal plane

The determination of the magnitude of the scoliotic component of deformation throughout the world is carried out in accordance with the Cobb method, described in 1948.

The first stage is localization of the apical and terminal vertebrae of the scoliotic arc. The apical vertebra is located horizontally. The terminal vertebra is the last of the inclined vertebrae. The lower terminal vertebra of the cranial arc can simultaneously be the upper terminal vertebra of the caudal countercurvature.

The second stage is drawing straight lines on the spondylogram, at the intersection of which the desired angle is formed. The first line is drawn strictly along the cranial end plate of the upper end vertebra, the second - along the caudal end plate of the lower end vertebra. In cases where the end plates are poorly visualized, it is permissible to draw the said lines through the upper or lower edges of the shadows of the roots of the arcs. Their intersection within the standard film is possible only in case of severe scoliosis. In other cases, the lines intersect outside the film, then, in order to be able to measure the angle of the scoliotic arc, it is necessary to restore the perpendiculars to both lines.

The third stage is measuring the obtained angle and recording the result on the radiograph and in the medical history.

Sagittal plane

The magnitude of thoracic kyphosis and lumbar lordosis is also determined according to the Cobb method. If a profile spondylogram of a patient with scoliosis is examined, it is necessary to measure the magnitude of curvature of the entire thoracic spine - from Th1 to Th2. It is quite acceptable to measure from Th4 to Th12. It is important that all measurements for a given patient are made at the same levels. Straight lines are drawn through the cranial endplate of the upper end vertebra and the caudal endplate of the lower end vertebra, at the intersection of which an angle is formed that characterizes the magnitude of the deformation. The magnitude of lumbar lordosis is measured from L1 to S1.

Horizontal plane

Deformation of the spinal column in the horizontal plane, i.e. rotation of the vertebrae around the vertical axis, is the main component of the mechanogenesis of idiopathic scoliosis. It is most pronounced at the level of the apical vertebra and progressively decreases in the direction of both end vertebrae of the arch. The most striking radiographic manifestation of rotation is the change in the location of the shadows of the roots of the arches of the apical vertebra on a direct spondylogram. Normally, in the absence of rotation, these shadows are located symmetrically relative to the midline of the vertebral body and its marginal structures. In accordance with the proposal of Nash and Moe, the degree of rotation is determined from 0 to IV.

The zero degree of rotation practically corresponds to the norm, when the shadows of the roots of the arches are symmetrical and located at the same distance from the lateral endplates of the vertebral body.

With grade I rotation, the root of the arch on the convex side of the scoliotic arch shifts toward the concavity and takes a position that is asymmetrical relative to the corresponding endplate and the root of the opposite arch.

At the III degree the root of the arch corresponding to the convex side of the deformation is located in the projection of the middle of the shadow of the vertebral body, and at the II degree rotation it occupies an intermediate position between the I and III degrees. The extreme degree of rotation (IV) is characterized by the displacement of the shadow of the root of the arch of the convex side of the arch beyond the midline of the vertebral body - closer to the medial lateral endplate. A more accurate determination of the degree of rotation is given by the Perririolle method, which involves the use of a special ruler - a torsiometer. First, it is necessary to determine the largest vertical diameter of the shadow of the root of the arch corresponding to the convex side of the deformation (point B). Then, points A and A ¹ are marked, located at the height of the "waist" - the vertebral body medially and laterally, the torsiometer is applied to the cyondylogram so that points A and A ¹ are located at the edges of the ruler. It remains to determine which of the torsiometer scale lines coincides with the maximum vertical diameter of the shadow of the root of the bow, point B.

When anomalies in the development of vertebrae and ribs are detected, they must be identified and localized. All vertebrae, both complete and supernumerary, must be numbered in the craniocaudal direction, the nature of the anomaly must be determined, and the correspondence of the ribs to the vertebrae and hemivertebrae must be clarified, and in the case of rib synostosis, which of them are blocked: Numbering of the vertebrae is mandatory not only in the presence of congenital anomalies, but in absolutely all cases, and in the craniocaudal direction. Neglect of this rule will inevitably lead to errors in planning and performing surgical intervention. Documentation of X-ray examination data must be as pedantic and methodologically uniform as the results of the clinical examination.

Special methods of radiographic examination

Tomography (laminography) is a layer-by-layer study of a limited area of the spinal column, which allows to clarify the features of the anatomical structure of bone structures that are not sufficiently visualized on conventional spondylograms. Magnetic resonance imaging (MRI) is a method that allows to study not only bone but also soft tissue structures, which, when applied to the spine, makes it possible to assess the condition of the intervertebral discs and the contents of the spinal canal. A large scoliotic component of the deformation complicates the picture; in these cases, a combination of MRI with myelography can be useful.

Computer tomography (CT) helps in difficult cases when it is necessary to localize the cause of radiculopathy in scoliosis or spinal cord compression. Such visualization is facilitated by performing CT after myelography, since with the presence of contrast it is easier to determine the location and nature of compression of the contents of the spinal canal. CT without contrast shows only narrowing of the spinal canal.

When examining the urinary system, it is necessary to take into account the frequent combination of spinal deformities, especially congenital ones, with pathology of an element of this system. Ultrasound of the kidneys and intravenous pyelography provide sufficient information that can influence the orthopedist's decision when planning a surgical intervention.

Laboratory diagnostics of scoliosis

Laboratory tests include general blood and urine tests, biochemical liver function tests, and a study of the blood coagulation system. Blood type and Rh status are determined without fail. The von Wasserman reaction and tests for AIDS are performed. The function of external respiration is also routinely examined. Determination of the immune status is highly desirable in order to perform correction in the preoperative period if necessary. If a biomechanical laboratory is available, it becomes possible to evaluate the patient's gait characteristics in the pre- and postoperative periods. This allows for additional objectification of the result of spinal deformity correction in terms of normalizing locomotion functions and restoring body balance. Mandatory diagnostics of scoliosis for a vertebrology clinic is photographing the patient from three points before and after surgery, as well as at the observation stages.