Scoliosis as a factor in the development of back pain

Among the structural deformations of the spine, the most frequent are idiopathic scoliosis (i.e., scoliosis with an unknown etiology), whose prevalence in the population reaches 15.3%. The frequent presence of dysraphic status in patients with idiopathic scoliosis allowed EA Abalmasova to identify dysplastic scoliosis in this group. At the same time, clinical manifestations, the nature of progression and the principles of predicting idiopathic and dysplastic deformations are often of the same type.

In foreign literature, the term "dysplastic scoliosis" is practically not used. In foreign countries, the leading principle of classification of idiopathic scoliosis is the age division of deformations proposed by JIPJames (1954):

• Scoliosis of young children: develop in the first 2 years of life, are more frequent in boys, more often left-sided, with long gentle arcs, in most cases regress.
• Juvenile scoliosis: develops between the 3rd year of life and the onset of puberty, more often in girls, more often right-sided, progressing.
• Scoliosis of adolescents: the onset of development coincides with the period of puberty and continues until the end of bone growth. In the vast majority of cases (up to 85%) are observed in girls, the progression is determined by the potency of bone growth.
• Scoliosis of adults: develop after the completion of bone growth.

Based on the study of the clinical course of idiopathic scoliosis in almost 25 thousand adolescents, ON KingJ.H. Mine, DS Bradford, RB Winter (1983) identified five typical variants of deformation. Later this division became known as the King's classification (after the first author's name). In the domestic literature, the classification of King'aenepBbie was published, unfortunately, only in 1998.

Classification of Idiopathic Scoliosis of Adolescents by King'y

Type of deformation	Deformation characteristic
Trail	S-shaped scoliosis: right-sided thoracic, Left-sided lumbar arch; Both arcs structural, lumbar more rigid; The amount of lumbar curvature exceeds The size of the thoracic arch; Deformation is usually compensated
Type II	S-shaped scoliosis: right-sided thoracic, left-sided lumbar arch; both arcs are structural; the size of the thoracic curvature exceeds the value of the lumbar arch; lumbar arch more mobile; deformation is usually compensated
Type III	Right-sided thoracic C-shaped scoliosis (usually from T4 to T12-L1); Lumbar curvature is absent or minimal; Decompensation is negligible or absent
Type IV	Long C-shaped right-sided thoracolumbar arch (lower vertebra - L3 or L4); significant decompensation
Type V	S-shaped double thoracic arch: upper left-sided arch (T1-T5), lower-right; both arcs are structural, the upper arc is more rigid

It is important to emphasize that the deformations presented in this classification are referred to in the foreign literature as "typical" idiopathic scoliosis of adolescents. A special value of the classification is also attached to the fact that at present, type II deformation by King'y is used as a base model in determining the tactics of superimposing the supporting structures of CD-tools.

Using the term typical scoliosis of adolescents entailed the introduction of the concept of atypical deformities. In the domestic literature, we have not found descriptions of atypical scoliosis, so pay special attention to them:

• left-sided scoliosis of mid- and lower thoracic localization,
• chest scoliosis with short 3-4-segment arches,
• scoliosis, not accompanied by torsion of the vertebrae.

The presence of signs of atypicality, regardless of the magnitude of deformation, is an indication for in-depth clinical and radiological examination. According to RB Winter, JE Lonstein, F. Denis (1992), with atypical deformations in almost 40% of cases, a sparse pathology of the spine or spinal cord - tumors, syringomyelia, neurofibromatosis, Arnold-Chiari syndrome, various variants of fixation of the spinal cord. At the same time, with typical idiopathic scoliosis, various variants of myelopathies and myelodysplasia were detected by the authors only in 3-5% of cases. These data explain the need for early MRI of the spine and spinal cord for atypical scoliosis in adolescents.

Determination of the probability of progression of scoliotic deformations. One of the key points in determining the therapeutic tactics for scoliosis is the prediction of a probable deformation progression. This indicator is determined by many factors - especially such as the magnitude of the scoliotic arc, the age of the child at the time of primary detection of deformation, the degree of maturity of the skeleton, etc.

Probability of scoliosis progression in adolescents (summary data).

Author	Year	Number of observations	The magnitude of the scoliotic arc	Probability of progression
Brooks	1975	134	Not specified	5.2%
Rogala	1978	603	Not specified	6.8%
Clarisse	1974	11O	10 ° -29 °	35%
Fustier	1980	70	<30 °	56%
Bunnell	1980	326	<30 ° -> 30 °	20% -40%
Lonstein	1984	727	5 ° -29 °	23%

It should be noted that deformations that have reached 45-50 °, most intensively progress during the growth period, but can also increase in patients who have completed growth.

X-ray features of progressive and non-progressive idiopathic scoliosis Mehta (1972) and, accordingly, bear the name of the first and second signs of M.N. Mehta:

The first sign of M.N. Mehta reflects the probability of progression of scoliotic deformity depending on the size of the rib-vertebral artery, if the difference in the values of the rib-vertebral angles a and b measured at the vertebral vertebrae level on the convex and concave side of the scoliotic arch does not exceed 20 °, the probability of deformation progression is 15-20 %; if this difference exceeds 20 ° - the progression of deformation is noted in 80% of cases;

The second sign of M.N. Mehta determines the probability of progression of scoliotic deformity depending on the projection ratio of the head of the vertebrae and the vertebral body on the convex side of the arc. The author detects two phases of the sign:

• phase 1 - the head of the ribs are projected to the side of the vertebral body: the probability of progression is low;
• phase 2 - the head of the rib on the convex side of the scoliotic deformation is superimposed on the vertebral body: the probability of progression is high.

The second sign of MHMehta actually characterizes the severity of torsional changes in vertebral vertebrae.

More recent studies, including ours, found that prognostically unfavorable for the progression of scoliotic arches in adolescents who did not grow up is the presence of II-IV degrees of torsion, measured by the pedicle method.

Some known prognostic signs of progression of scoliosis are at present more of historical interest, as they are not widely used in practice or are not reliable enough to foresee the course of deformation. One of them is the determination of the Harrington stability zone located between two perpendiculars, restored through the roots of the arcs L5 of the vertebra to the line connecting the wings of the ileum. If most of the vertebral vertebra of the lumbar arch is located inside this zone, deformation is considered stable, if outside of it - progressing. The concept of a "zone of stability" was used by the author also to determine the extent of the posterior spinal fusion and to determine the supporting arcs of the vertebrae, which, when the distractor is installed, must be located inside the stability zone.

Historical interest is also a sign of progression of scoliosis, described by I.I. Konom, but not received statistical confirmation.

Concluding the section on predicting scoliotic deformities, we should note the following: an absolutely objective evidence of the progression of the deformity of the spine is the radiographic confirmation of the increase in the scoliotic arch. In cases where this is possible, we consider it necessary to foresee, with a certain degree of certainty, during a primary examination, a possible course of deformation and inform the patient and his parents about it. Of particular importance in the dynamic observation of a patient with scoliotic deformities is the frequency (multiplicity) of examinations of the patient and the conduct of control radiographs.

With prognostically favorable deformations of the spine, the patient should be examined by an orthopedist or a vertebrologist every 6 months, and x-ray examination should be performed once a year. If the risk of progressing scoliosis is large enough, or if the parents or the patient himself is subjectively marked by a build-up of deformity, a specialist examination and an X-ray examination should be performed every 4-6 months.

[1], [2], [3], [4], [5], [6]