S-shaped scoliosis

Any scoliosis is a spinal deformity, and S-shaped scoliosis is determined when, along with a frontal curvature resembling the letter C, there is a second lateral curvature — compensating, giving the spinal column the shape of the letter S.

This type of deforming dorsopathy in most cases affects the thoracolumbar region of the spinal column — the thoracic and lumbar regions. According to ICD-10, the scoliosis code is M41.0 M41.9.

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Epidemiology

WHO statistics on scoliosis (2012-2014) indicates the seriousness of this pathology on a global scale: spinal curvature was diagnosed in 28 million patients, and 93% of them are children aged 10-16.

And experts from the National Scoliosis Foundation (USA) predict an increase in this figure by 2050 to 36 million.

To date, it is possible to find out the cause of the curvature in approximately 20% of cases of scoliosis. About 10% of patients have adolescent idiopathic S-shaped scoliosis, and its prevalence is up to 3% of the population. Moreover, 90% of cases are related to adolescent girls.

The prevalence of congenital  scoliosis in children  is estimated at 1-4%.

[2], [3], [4], [5]

Causes of the s-shaped scoliosis

As vertebrologists note, S-shaped scoliosis in children and adolescents occurs during the period of the most active growth of the spine - at the age of 7-15 years, and four times more often in girls (who grow faster during this period). If a C-shaped thoracic scoliosis is formed in the thoracic spine, then when engaging the lumbar spine in the pathological process, two oppositely directed arcs are formed, and S-shaped scoliosis develops.

Among the explanations for the etiology of spinal curvature of this form are the following most likely causes:

• genetic predisposition (although specific genes have not yet been identified);
• skeletal pathology ontogeny - anomalies its formation in utero (between the 6th and 8th week of pregnancy) leading to birth defects, such as  spina bifida  (spina bifida);
• spinal injuries sustained during childbirth or early childhood;
• violation of posture in children ;
• neuromuscular conditions accompanying various types of  muscular dystrophy, torsion dystonia, as well as cerebral palsy and poliomyelitis;
• short leg syndrome ;
• multiple hereditary osteochondromas (osteochondral exostoses) of the spine;
• osteochondrosis of the lumbosacral spine  (in adults);
• Systemic rheumatic diseases - lupus erythematosus, rheumatoid arthritis, polyarthritis, accompanied by inflammation of the connective tissue (fascia);
• juvenile onset (juvenile), ankylosing spondylitis, or  ankylosing spondylitis ;

There is also the so-called syndrome of scoliosis, including S-shaped, which is part of the clinical picture of a number of congenital syndromes with problems of the musculoskeletal system, in particular,  Angelman syndrome, Down syndrome, Prader-Willi, Ehlers-Danlos, hereditary osteosclerosis (Alber's disease) Schonberg) and others.

But idiopathic S-shaped scoliosis, which is considered the most commonly diagnosed type of spinal curvature in adolescents aged 10 to 17 years, in most cases develops spontaneously - without identifiable causes. Regarding the etiology of this disease, many theories have been advanced, including hormonal imbalance, bone growth asymmetry and muscle imbalance. Approximately 30% of patients have a family history of scoliosis, which is considered to be indirect evidence of possible genetic prerequisites.

Read also -  Scoliosis: what causes and how to recognize?

Risk factors

Among the risk factors for the development of scoliosis, experts note:

• prepubertal age and the associated increased growth of children, whose skeleton is in the process of development and is considered immature before the end of puberty;
• female;
• the presence of deforming dorsopathies among close relatives;
• imbalance of load on the spinal column and weakening of the joints;
• vertebral injuries;
• the development of  osteoporosis  in adults and  spondylarthrosis  in the elderly;
• the presence of  myofascial pain syndrome  (compelling to look for a position of the body and posture to reduce pain).

There are also a number of factors that may increase the risk of disturbances in the formation of somites of the chord and fetal neural tube during pregnancy, with the development of congenital fetal abnormalities and  congenital scoliosis  in an infant. This may be fetal hypoxia, placental insufficiency, gestational diabetes, the use of antiepileptic drugs or steroids, prolonged febrile fever of pregnant women, the effects of toxic and radioactive substances on their body.

[6], [7]

Pathogenesis

A healthy spine, when viewed in lateral projection, has natural anatomical curves: forward - in the neck and lower back (lordosis) and back - in the thoracic and sacral regions (kyphosis). When viewed from the back, the spinal column runs strictly vertically in the middle of the back.

However, with scoliosis, the vertical position of the spine is disturbed, and the pathogenesis of its curvature, which is currently not fully understood, is seen in the asymmetric growth of the vertebrae. Based on well-known  anatomical and biomechanical features of the spine, experts investigated the mechanisms of growth of the vertebrae, which, as children grow, lengthen and become larger.

But the growth of the vertebral bodies in front of the dorsal (posterior) part is uneven. Thus, a decrease in dorsal growth inhibits the growth of ventrally (lower) vertebral bodies with an increase in their height, causing torsion - twisting around the internal posterior longitudinal ligament towards the concave side with the formation of rotational lordosis and disruption of normal thoracic kyphosis.

On the surfaces of vertebral joints nuclei of ossification (ossification) are gradually formed, and their cartilage matrix is filled with bone tissue, fixing the defect.

In addition, when the frontal displacement of the vertebral bodies revealed their "jamming" due to the deformation of the intervertebral spaces; anomalies of bone growth plates (growth zones), dystrophy and degenerative changes of cartilage are noted; reduced bone mineral density.

In numerous clinical studies in adolescent patients with idiopathic S-shaped scoliosis, violations of the biomechanics of the spine have been identified, correlated with fibrosis of the paraspinal muscles supporting the spine and its rotational movements.

And, perhaps, the deficit of the hormone melatonin produced in the epiphysis, which stimulates the proliferation and differentiation of young bone cells (osteoblasts), plays a significant role in the pathogenesis of adolescent idiopathic S-shaped scoliosis.

[8], [9], [10], [11], [12], [13]

Symptoms of the s-shaped scoliosis

Skipping the first signs of S-shaped curvature of the spinal column is simple: at first (as long as the angle of curvature is no more than 5 °), the symptoms are absent, except for cases of congenital syndromal scoliosis. In infants, symptoms may include a bulge on one side of the rib cage, bulging of the scapula, the baby may lie curved to one side.

In adolescents, the most common symptoms of S-shaped scoliosis are:

• small deviation of the head (relative to the center position);
• asymmetry of the ribs (which bulge forward);
• changes in the horizontal position of the waistline;
• increase the height of one shoulder girdle and / or shoulder blade compared with the opposite side;
• pain localized in the back, chest and lower limbs.

Lumbar S-shaped scoliosis can cause one hip to appear higher than the other with a feeling of shortening of one leg, which makes the habit of standing on one side in a standing position — with excessive stretching of the intercostal muscles (with contralateral curvature) and weakening press.

The fourth degree of curvature often leads to the formation of a gibus (costal hump) and back pain. Read more -  Scoliosis, as a factor in the development of back pain.

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Stages

The severity of the disease is determined by the degree of curvature of the spine - depending on the angle of rotation of the spinal column, visualized on an x-ray and defined as the Cobb angle. There are four such degrees:

• if the angle of curvature does not exceed 10 °, it is 1 degree;
• more than 10 ° but less than 25 ° - 2 degree;
• in the range of 25-50 ° - 3 degree;
• more than 50 ° - 4 degree.

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Forms

Types or types of S-shaped curvature of the spine differ depending on the location:

• S-shaped scoliosis of the cervical and cervicothoracic with curvature in the cervical spine (with apex on the vertebrae TIII-TIV);
• S-shaped thoracic scoliosis or thoracic, which is observed in the thoracic spine (apex in the middle of the back - TVIII-TIX vertebrae, curvature limited by TI-TXII vertebrae) and is usually diagnosed in children or adolescents;
• S-shaped thoracolumbar scoliosis or thoracolumbar - affects the vertebrae of both the lower thoracic and the upper lumbar part of the spine (apical vertebrae TXI-TXII). Often, this is a congenital curvature that is formed in the womb during the sixth to eighth weeks of gestation and is detectable at birth. This may be a secondary effect of the neuromuscular state (for example, spina bifida or cerebral palsy);
• S-shaped scoliosis of the lumbar spine (lumbar) - more common in adults (vertex marked below the vertebrae TXII-LI).

When the curvature of the spine is directed to the left, S-shaped left-sided scoliosis is diagnosed, and if to the right, right-sided S-shaped scoliosis is diagnosed.

Also distinguish congenital S-shaped scoliosis in children, neuromuscular and degenerative scoliosis in adults.

Complications and consequences

If scoliosis is not treated, the spine will continue to deform and problems may arise over time.

According to the observations, mild S-type scoliosis (up to 10 °) progresses in 22% of patients. When the angle of curvature is determined to a level of up to 20 ° or higher, the risk of progression increases to 65–68%. According to foreign orthopedists, in 36% of cases of idiopathic scoliosis of adolescents, the curvature increased after 20-22 years by more than 10 °.

Degenerative S-shaped scoliosis in adults older than 45 years may develop towards an increase in the angle of curvature by 0.3 ° per year, and in people older than 65 years old - by 2-2.5 ° annually. But the highest risk of progression in adolescent idiopathic S-shaped thoracic scoliosis is 58-100%.

Complications and consequences of this type of spinal deformity include chronic pain in the back, chest, legs; problems with the heart and lungs, a significant decrease in physical endurance and activity. Also, the curvature of the spinal column can cause damage to the spinal cord, the consequences of which lead to paralysis of the lower extremities (paraplegia) and disability.

In women, 3-4 degrees of S-shaped scoliosis limits their ability to bear and give birth to a child. And young people with a curvature of more than 10-15 ° do not call in the army.

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Diagnostics of the s-shaped scoliosis

To establish an individual therapeutic strategy, diagnosis requires careful clinical and visual examination with anthropometry. See -  Visual criteria for statics and dynamics of the musculoskeletal system.

To determine the state of the vertebral joints used instrumental diagnostics:

• radiography with  spondylometry ;
• spinal computed tomography  (CT);
• MRI of the thoracic and lumbar spine;
• electromyography (EMG).

[17], [18], [19], [20]

Differential diagnosis

Based on the results of the examination, differential diagnosis can reveal other back problems, such as decreased motor activity, myasthenia or spasticity, indicating damage to the upper motor neurons, as well as some similarity to myelomeningocele and syringomyelia associated with spinal cord alteration.

See more -  Some diseases involving spinal deformity.

[21], [22], [23]

Treatment of the s-shaped scoliosis

The main goal on which the treatment of scoliosis is focused is an attempt to prevent further curvature of the spine. Conservative treatment of idiopathic S-shaped scoliosis with a curvature angle of less than 40 ° consists of observation, special exercises and fixation of the spine.

Congenital scoliosis, which has the worst prognosis, requires treatment from the first days of a child’s life. Experience shows that only a quarter of cases can be done without fixation, and 75% of cases require surgery, which is carried out at the age of one to four years.

For correction of the lateral curvature in some children, traction therapy can be used - longitudinal stretching of the spine with the help of special equipment.

In addition, surgical treatment by spinal fusion (fixation of the vertebrae with metal rods, screws, hooks) is considered as a necessary option when unsuccessful attempts to stop the further curvature of the spine or in cases of severe degree of deformity. All the details in the material -  Scoliosis: surgery

Most adult patients (aged bone maturity) with idiopathic S-shaped scoliosis - with a curvature of less than 20 ° and not exceeding 40 ° - do not need surgical intervention or fixation, but they need physical therapy and physiotherapy (at least one and a half hours daily), as well as periodic examinations of the attending orthopedic surgeon or vertebrologist - with visualization of the spine using x-rays.

When the curvature in adolescents progresses (with a Cobb angle between 20-30 °), bracing (“vertebral braces”) is used to reduce the speed of the pathological process and transverse correction of the deformity. There are different types of orthopedic staples, they are selected individually and used a certain number of hours per day.

In order to stabilize the spine, reduce the load on the deformed vertebral bodies and restrain further curvature, a redressing (compensating) corset or thoracolumbosacral  orthosis is also used.

In more detail -  Treatment of scoliosis.

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Physiotherapy

With deformities of the spinal column, the most important role is played by physiotherapy treatment. Currently, exercise therapy for S-shaped scoliosis is based on three-dimensional scoliosis therapy and special gymnastics developed by Katharina Schroth, and the recommendations of the International Society for Orthopedic and Rehabilitation Scoliosis Treatment (SOSORT). Depending on the degree of curvature and its localization, an individual exercise program is drawn up for each patient, and the physiotherapist must have appropriate qualifications and sufficient clinical experience in correcting scoliosis.

Exercises for S-shaped scoliosis - isometric and isotonic - are aimed at slowing, stopping and correcting the curvature, as well as preventing muscular hypotrophy. And this is achieved by the stabilization of muscle tension and activation of the paravertebral muscles, the formation of the skill of postural self-control and special breathing exercises.

Asymmetric exercises for S-shaped scoliosis, including side slats and stretch marks, as well as some yoga asanas (Apanasana, Adha Pavanmuktasana, Jathara, Vakrasan, Triconasana, Parigahasana), have a significant positive effect. The complex of such exercises contributes to: strengthening the muscles of the back and weak lateral muscles on the side of the bulge of the ribs; stretching dense (spasmodic and hyperactive) lateral muscles from the concave side; increased mobility and strength of the thigh and quadriceps muscles; strengthen the abdominals and the expansion of the chest.

Read:

• Exercises for the lower back
• Exercises to strengthen the back muscles for children
• Exercises for posture for children

Since the curvature leads to musculoskeletal imbalance, therapeutic massage is recommended for S-shaped scoliosis. Massage courses contribute to a better distribution of the load on the back muscles and support the musculoskeletal functions of the spine, and can also help reduce the displacement of the vertebrae.

In the treatment of this disease, muscle electrostimulation (electromyostimulation) of the lateral surface of the body is used.

[25], [26]

Prevention

Most cases of S-shaped scoliosis are idiopathic, and this means that prevention of spinal curvature is in correct posture, sufficient physical activity (especially swimming is useful), good nutrition, mandatory monitoring of the spinal state, especially in the presence of risk factors for the development of this dorsopathy.

[27], [28]

Forecast

For children with scoliosis, the prognosis varies depending on its severity, age, and overall health. Mild idiopathic S-shaped scoliosis in older children and adolescents is corrected by physical therapy.

Congenital syndromes, neuromuscular and autoimmune conditions can be incurable, and spinal deformity often leads to disability.

[29], [30]