Scoliosis of the 4th degree: what to do, treatment, disability

In scoliotic deformation of the spine, the degree of curvature is of decisive importance for the choice of treatment tactics and predicting its success, and the most difficult case is grade 4 scoliosis.

This degree means that the lateral deviation of the spine (Cobb angle, measured on an X-ray) is 50° or more. [ 1 ]

Epidemiology

The prevalence of scoliosis of various degrees is estimated at 4-8% of the general population. And the prevalence of idiopathic scoliosis, according to foreign sources, is from 0.5% to 4.5%. At the same time, approximately 30% of patients with idiopathic scoliosis have a family history of the disease.

According to the American Academy of Orthopedic Surgeons, idiopathic scoliosis is ten times more common in girls over 10 years of age (in whom the ossification process occurs somewhat faster) than in boys.

And experts from the Scoliosis Research Society note that grade 4 scoliosis is diagnosed in 0.04-0.3% of cases with a female to male patient ratio of 7:1.

80% of idiopathic scoliosis occurs in adolescents (11 to 18 years old), while childhood scoliosis (up to three years old) accounts for 1% of cases, and juvenile scoliosis (in children 4-10 years old) accounts for 10-15%.

Scoliosis developing in adults (if it does not develop in adolescence) has a prevalence of more than 8% in those over 25 years of age, and in people 60 years of age and older it increases to 68%, however, the statistics for the fourth degree of this type of pathology are unknown.

Causes Fourth-degree scoliosis

In the majority of patients – approximately 8 out of 10 cases – the causes of scoliosis cannot be identified, although, as is known, this disease often runs in families: in first-line relatives, the incidence rate is 11%, in second-line relatives – 2.4%.

So the version of genetic predisposition in cases of familial idiopathic scoliosis is considered, however, specific genes, polymorphism, duplication or mutations of which cause anomalies in the development of the spine and the process of its deformation have not yet been precisely identified. Studies on gene linkage show that loci on at least one and a half dozen chromosomes may be related to the development of this pathology. For example, the involvement of the GPR126 gene on chromosome 6, which codes for the development of cartilage and is associated with trunk growth, has been identified. [ 2 ]

Although idiopathic scoliosis of the 4th degree (i.e. of unknown etiology) is most often diagnosed, possible causes of lateral deformation of the spine may be related to:

• with intrauterine anomalies or birth injuries. For example, grade 4 thoracolumbar scoliosis in children may be caused by a phylogenetic pathology - a defect in the embryonic neural tube leading to incomplete closure of the spinal arch, i.e., spina bifida, or transverse expansion of the vertebrae (plastinospondylia), or such an anomaly of the spinal cord as diastematomyelia;
• with deformation of the facet joints of the spine in spinal gliomatosis (syringomyelia);
• with spinal muscular atrophy or muscular dystrophy (such scoliosis is called neuromuscular or myopathic);
• with neurofibromatosis (hereditary Recklinghausen disease);
• with spinal dysraphism affecting the musculoskeletal structures and ligaments of the spine;
• with spinal tumors;
• with hereditary disorder of methionine metabolism (homocystinuria) and mucopolysaccharidosis;
• with such mesenchymal disorders as Marfan syndrome, Ehlers-Danlos syndrome, Klippel-Feil syndrome, etc., it is diagnosed as mesenchymal or syndromic scoliosis;
• in older patients – with degenerative spondylosis (the formation of osteophytes due to the proliferation of bone tissue in the vertebral joints).

See also –

• Some diseases accompanied by spinal deformation
• Scoliosis in children
• Congenital scoliosis

Scoliosis of the 4th degree in adults with a mature skeleton differs from scoliosis in childhood. In addition to the fact that in adults it can be present from adolescence – after surgical treatment or without it (as an advanced case), lateral curvature can develop as a new pathology (scoliosis de novo) – with degenerative changes in the lumbar and lumbosacral spine. [ 3 ]

Degenerative lumbar or lumbar scoliosis of the 4th degree in the elderly (aged 65 years and older) can be the result of instability or displacement of the lumbar vertebrae (spondylolisthesis), as well as a consequence of surgical intervention (laminectomy) performed for compression of the spinal nerves of various etiologies. However, in most such cases, the curvature of the spine does not exceed 2 degrees.

Risk factors

As a rule, scoliosis begins during periods of growth spurts before or during puberty (from 10 to 16 years), as well as increased growth of the chest (which begins at 11-12 years of age). Therefore, when listing the risk factors for this type of spinal deformity, vertebrologists first name the age factor.

This is followed by being female (scoliosis develops much more often in girls than in boys) and having a family history of scoliosis.

The risk of spinal curvature is increased in case of persistent posture disorders in childhood and adolescence; injuries to the vertebrae and costovertebral joints; myofascial pain syndrome (with compensatory pathological changes in posture); congenital deformation of the anterior chest wall (pectus excavatum); the presence of arthrosis of the intervertebral joints (spondyloarthrosis) and other degenerative-dystrophic diseases of the spine in adults; hyperestrogenism in adolescent girls and hypoestrogenism in women (especially in postmenopause); deficiency of magnesium, vitamins D and K in the body, as well as insufficient body weight.

Pathogenesis

Attempts to explain potential mechanisms of development – the pathogenesis of scoliosis – led researchers to recognize the polygenic nature of this disease with a certain impact on the structures of the musculoskeletal system of genetic factors, neurocirculation disorders, hormonal shifts (including sex steroids and melatonin, which stimulates the division of osteoblasts) and features of general metabolism. [ 4 ]

Most of the proposed versions come down to the leading pathogenetic role of anomalies of the growth plates (epiphyseal plates) of the vertebral bodies - secondary centers (points) of their ossification, as well as asymmetric growth of the spine. The mechanism of vertebral growth in height is similar to that in long bones: endochondral ossification (ossification) in the growth plates. And an increase in their diameter occurs through appositional growth at the ossification points adjacent to the intervertebral discs.

How can scoliosis of the 4th degree develop in children? The longitudinal growth of the vertebral body from the primary ossification points occurs throughout childhood (especially rapidly in the first three years of a child's life), adolescence and youth. But during puberty, growth intensifies with the appearance and activation of five secondary ossification centers on the body of each vertebra. [ 5 ]

Violation of the ossification process during overload of the growth plates on the concave side of the vertebral bodies results in their wedge-shaped deformation, which provokes lateral bending of the spinal segment in the frontal plane and axial twisting of the vertebrae - torsion. This is when the vertebrae are rotated relative to their own axis in the transverse plane: their bodies turn towards the convexity of the scoliotic arc, while the spinous processes extending from the vertebral arc are rotated in the direction of the concave part of the arc.

With muscular dystrophy or atrophy of the spinal muscles, scoliosis or kyphosis, or both curvatures at the same time, can develop. As the spine grows, the strength that supports the vertical position of the spine weakens, and eventually its curvature to the right or left occurs in the upper or middle part, forming a C-shaped scoliosis, which can progress to grade 4 (with a Cobb angle of 80° or more). [ 6 ]

Symptoms Fourth-degree scoliosis

In patients with stage 4 scoliosis, symptoms are caused by the spine not only being curved but also twisted. As a result, the rib cage loses its symmetry and becomes deformed, which leads to the displacement of the thoracic organs.

So, grade 4 thoracic scoliosis or thoracic scoliosis, in which the arc of curvature is formed by several thoracic vertebrae - in the interval between the third and ninth, is manifested by deformation of the chest, distortion of the suprascapular region, protrusion of the scapula, formation of a costal hump (front or back), back pain and shortness of breath.

A second curvature in the opposite direction may form slightly below the middle of the thoracic spine, and then thoracolumbar (thoracolumbar) S-shaped scoliosis of the 4th degree is determined. With it, due to the torsion of the vertebral bodies, the chest and pelvis turn in different planes - with a distortion of the pelvic region (skewness), different lengths of the lower limbs and lameness when walking.

Lumbar or lumbar scoliosis of the 4th degree in 75% of cases is accompanied by spinal pain associated with pelvic tilt and protrusion of the upper edge of the ilium, degenerative changes in the facet joints and displaced intervertebral discs, as well as overload of the paravertebral muscles that resist progressive deformation.

Lumbo-sacral scoliosis of the 4th degree develops in rare cases, since all five vertebrae of the sacral section gradually fuse at the age of 18-25, forming a solid bone - the sacrum. But if lateral curvature of this localization occurs, then its symptoms are similar to lumbar scoliosis.

Pregnancy and 4th degree scoliosis

Experts classify scoliosis of such a high degree as a factor that increases the risk of disorders during pregnancy – both for the woman and for the future child.

Firstly, as the gestation period increases, the load on the spine increases, especially in the lumbar region (where hyperlordosis is formed), and a pregnant woman with grade 4 lumbar scoliosis will experience significantly increased pain. [ 7 ]

Secondly, the uterus grows with an increase in the height of its fundus, and with thoracic or thoracolumbar scoliosis of the 4th degree, this will lead to serious problems associated with the displacement of the uterus, since the chest is deformed, the internal organs are displaced, and the pelvic part is asymmetrical. Therefore, placental insufficiency and disturbances in the mechanisms of uteroplacental blood circulation are observed. In addition, a decrease in the volume of the lungs with such a disease of the spine is fraught with insufficient oxygen supply to the fetus, that is, perinatal hypoxia.

Pregnancy with grade 3 and 4 scoliosis can be interrupted at any time due to placental abruption (even when it is located normally); in some women with such a diagnosis, progression of scoliosis deformity of the spine is observed both during pregnancy and after birth.

Natural childbirth with grade 4 scoliosis of the thoracic spine is possible if the patient underwent surgical treatment for scoliosis several years before. But even in such cases, according to some data, almost half of women undergo a cesarean section. [ 8 ]

Complications and consequences

What is the danger of grade 4 scoliosis? With this degree of deformation of the spinal column, an uncorrectable change in the body's center of gravity occurs, which, in turn, leads to an imbalance in the load on the muscles, vertebral joints and ligaments, which causes limited mobility and pain of varying intensity.

The normal anatomical position and functions of the organs located in the chest are disrupted. In particular, due to the reduction in lung volume in thoracic and thoracolumbar scoliosis, pulmonary hypertension, dyspnea, and chronic bronchitis develop. The pressure in the pulmonary circulation also increases, causing the right sections of the heart to expand (the so-called pulmonary heart).

A change in the chest size at a Cobb angle of 60° leads to a disruption of the mechanical functions of the ribs and respiratory muscles (intercostal and diaphragm), a decrease in the total capacity of the lungs and clinically expressed pulmonary dysfunction in the form of shortness of breath during physical exertion and a decrease in the amount of oxygen entering the body. At a Cobb angle of 80°, hypopnea/apnea is observed during sleep.

In addition, the consequences and complications of grade 4 scoliosis include: pain in the intestinal area; development of deforming spondyloarthrosis; spasms of asymmetrically overloaded muscles; neuropathies manifested by paresthesia of the extremities.

Scoliosis of 1-3 degrees in children or adolescents - before complete ossification of the vertebrae - is considered progressive. Despite the fact that the bone connection of skeletal structures (synestosis) and ossification of the vertebrae is completed by about 25 years, progression of scoliosis of the 4th degree is noted in adulthood. As clinical practice shows, lumbar scoliosis is less prone to progression than others; most often, scoliosis of the 4th degree of the thoracic spine progresses. According to studies, the average increase in deviation is 2.4 ° per year for five years, and in adolescents, scoliosis progresses over 20 years by an average of 10-12 °.

Diagnostics Fourth-degree scoliosis

For more details on how diagnostics are performed, see – Scoliosis diagnostics

Instrumental diagnostics see - X-ray of the spine in three projections, CT of the spinal column. [ 9 ]

Read also:

• Methods of examination of the spine
• Spondylometry

Treatment Fourth-degree scoliosis

Attempts at conservative treatment of this degree of scoliosis can only be undertaken in children before the onset of puberty.

Although numerous clinical studies have shown that treatment of grade 4 scoliosis without surgery – physiotherapy (lateral electrical muscle stimulation), exercise therapy, massage – is ineffective.

Some experts claim that exercises for stage 4 scoliosis are contraindicated due to severe skeletal deformation and serious physical limitations. Others believe that in cases of juvenile curvature of the spine, that is, in children aged 4-11, three-dimensional exercises and special breathing techniques according to the Katharina Schroth method can have a therapeutic effect: strengthening and normalizing the tone of the muscles of the trunk, pelvis, lower limbs; improving the functioning of the lungs and heart. [ 10 ]

Therapeutic massage for grade 4 scoliosis is carried out in courses – with the aim of correcting the load on the paravertebral muscles.

For curvatures exceeding 40-50°, surgical treatment by spondylodesis is usually recommended - fusion of several vertebrae with bone grafts with mechanical fixation using specially designed metal structures; instead of static structures, methods of one-stage correction of deformation with subsequent dynamic fixation with a special endocorrector are used. Adults with degenerative scoliosis and spinal stenosis may require decompression surgery with fusion of the vertebrae; for lumbar scoliosis, wedge osteotomy is used.

Read more – Scoliosis: surgery

In idiopathic scoliosis of the 4th degree, it is very rare to make the spine absolutely straight, but it is possible to provide significant correction of both the thoracic and lumbar scoliotic arcs: to reduce the main frontal curve by approximately 50%, the torsion of the vertebrae by 10%, and the vertical position of the spinal column by an average of approximately 60%. [ 11 ]

During the postoperative rehabilitation period, gymnastics for grade 4 scoliosis is individually selected, which is aimed at relieving muscle spasms, restoring joint mobility and normal blood circulation.

On the other hand, early and late complications and consequences after surgery for grade 4 scoliosis cannot be ruled out:

• during surgery there may be significant blood loss, venous air embolism, respiratory distress syndrome, spinal cord injury;
• development of secondary infection;
• errors in fixation of vertebrae with the development of pseudoarthrosis;
• neurological damage with loss of some functions.

Correction of scoliosis with successful fusion of the posterior vertebral bodies in children and adolescents may be complicated by the continued growth of the anterior vertebral body, which worsens its curvature and twisting. [ 12 ]

Prevention

If you look at grade 4 scoliosis as an advanced case of scoliotic disease, then it immediately becomes clear what its prevention consists of.

These are preventive orthopedic examinations of schoolchildren - to identify the initial stage of any curvature of the spine, explain (to both children and parents) the principles of correct posture and the consequences of their violation, performing exercises for posture for children, and swimming lessons.

The detected scoliotic deformity must be treated promptly!

Forecast

Scoliosis of this degree can only be controlled, since it is a lifelong diagnosis. And often the prognosis is not very encouraging even with all attempts to stop the progression.

Many patients find it difficult to work, so a medical and social examination in the established manner can grant disability for grade 4 scoliosis (with subsequent registration of appropriate social benefits).