Scoliosis of the lumbar spine

Curvature of the lumbar spine - lumbar scoliosis - is often formed in the form of a compensatory reaction in the primary deformity of the thoracic spine, or is formed primarily. The pathology is characterized by a one-sided shortening of the lower limb, as well as a pronounced asymmetry of the waist zone. The problem grows slowly, in the early stages it can be corrected, but at advanced stages it can cause the development of serious complications.[1]

Epidemiology

Currently, scoliosis is a fairly common disorder. Doctors voiced disappointing forecasts and declare that over the years the problem will only get worse, which is due to the relatively sedentary lifestyle of modern youth, prolonged sitting at the computer, malnutrition, etc.

It is among schoolchildren at the stage of active formation of the musculoskeletal system that the overwhelming majority of cases of scoliosis appear. In some patients, the pathology persists forever and only progresses over the years.

Fortunately, modern diagnostic methods can detect pathological curvature even at the stage of absence of clinical manifestations.

According to general statistics, lumbar deformities of the spinal column are extremely common - especially in European countries and the United States. A slightly lower incidence is noted in Africa and Asia, where the level of education is frankly lagging behind. Here children spend less time at tables and desks, but they move much more. But it is inactivity and prolonged improper sitting at the table that are considered the main factors in the formation of spinal deformities. The prevalence of lumbar scoliosis among the adult population ranges from 2% to 32%; a recent study in older volunteers found a prevalence of over 60%. [2]The  [3]prevalence of degenerative lumbar scoliosis ranges from 6% to 68%. [4], [5]

Girls suffer from lumbar scoliosis almost 5 times more often than boys. Experts explain this fact by the fact that girls are less engaged in sports activities, but spend more time studying.

Among all types of scoliotic curvature, the most common is thoracolumbar scoliosis: it is found in 4 out of 10 patients who have spinal deformities.

In about 15% of patients, only lumbar scoliosis is diagnosed, which in most cases is asymptomatic and is almost never complicated (complications are noted in only 3% of cases).

Causes of the lumbar scoliosis

Lateral deformity of the lumbar segment of the spinal column may be due to the following reasons:

• congenital defects in the development of the spine;
• genetic pathologies;
• traumatic injuries, including fractures, displacements, etc.;
• postoperative complications;
• bone tuberculosis;
• physical inactivity, passive lifestyle;
• improperly organized sleeping and working place (especially for children);
• degenerative processes affecting the musculoskeletal system, osteoporosis;
• rheumatism;
• endocrine diseases;
• overweight, overweight;
• tumors affecting the back and spinal column;
• intervertebral hernial protrusions;
• unequal length of the lower limbs, irregular shape of the foot (flat feet, etc.);
• infantile cerebral palsy, syringomyelia;
• psychogenic disorders;
• metabolic disorders.

The disorder is most often formed during the period of bone growth - that is, in childhood and adolescence. In this case, the first place is occupied by idiopathic scoliosis - a curvature, the causes of which cannot be established. 

Risk factors

The most common risk factors are congenital malformations:

• dystrophic changes in the vertebral arches;
• hemivertebrae;
• underdeveloped lower segment of the spinal column;
• an inappropriate number of vertebrae in the lower back and sacrum (lumbarization);
• birth damage.
• In about 80% of cases of non-idiopathic scoliosis, risk factors become;
• excessive body weight;
• traumatic back injuries;
• infantile cerebral palsy, disturbances in the shape of the foot, rheumatism;
• hypodynamia, passive lifestyle, weakness of the muscle corset;
• period of pregnancy.

The risk group includes school-age children, students, office workers who are forced to sit at a desk or table for a long time. At the same time, the problem would not arise so often if the workplace were properly organized.

Pathogenesis

The spine includes 32-34 vertebrae. In this case, the vertebral section is represented by 5 vertebrae L1-L5.

The vertebrae of different departments differ in different shapes, due to their different purpose and function. Normally, the spinal column has four physiological curvatures. Specifically in the lumbar region, there is kyphosis - posterior bulge. Due to this bend, vertebral flexibility is formed. [6]

Some traumatic, degenerative or age-related lesions of the spine lead to the fact that, in addition to physiological, pathological curvatures appear. In adulthood, the most common causes are degenerative-dystrophic processes, bone loss (osteoporosis), bone softening (osteomalacia). In some people who have undergone surgery on the spine, scoliosis becomes an unfavorable postoperative consequence. [7]

Degenerative deformity is usually diagnosed in patients over 40-45 years old. Among older people, and especially among females, the disorder often develops against the background of osteoporosis. With a combination of these pathological factors, the spinal column loses the ability to maintain a normal position and bends. [8]

In degenerative processes, the spinal column loses its structural stability and balance. With an increase in the angle of the scoliotic arch, degeneration of the spine increases, which is interrelated. There is a gradual narrowing of the intervertebral discs, wear of cartilage and articular surfaces, and back pain appears. [9]

Symptoms of the lumbar scoliosis

Lumbar scoliosis is accompanied by noticeable changes almost throughout the body: a person's shoulder drops, a stoop is formed, the pelvic region is bent, the lower limbs become multilevel. As the scoliotic arch increases, the signs become more pronounced, there is a crunching sound while walking, pain and paresthesia appear. 

The first signs do not appear immediately: at first there is a slight stoop, which is difficult for a non-specialist to notice. Further, other symptoms appear, which can already be paid attention to:

• the shoulders become asymmetrical (located at different levels);
• head tilts to the side;
• an arc of deformation is visually visible from the back;
• hips are of different heights;
• often worried about back pain;
• ribs on one side are more convex;
• digestive disorders appear;
• often worried about intercostal neuralgia;
• weakness, numbness of the limbs may appear.

Pain with scoliosis of the lumbar spine is one of the first signs of a disorder. By the nature of the pain, pulling, by localization - the lower part of the spinal column, and as the process grows, patients notice pain in the thighs, groin, in the projection of the sacroiliac joints, in the knee joint, ankle, foot, Achilles tendon. As the deformation worsens, the internal organs shift, their work is disrupted, and the pain syndrome increases. [10]

With the appearance of pelvic misalignment, the symptoms expand. Appear:

• hip pain when walking, lameness, tendency to fall;
• motor stiffness;
• different lengths of the lower limbs;
• disorder of the function of the urinary system, genitals and intestines;
• muscle imbalance (atrophy of some muscles against the background of overstrain of others).

Lumbar scoliosis and misalignment of the pelvis lead to an imbalance of the trunk: there is a gradual tilt of the trunk axis towards the apex of the curvature. [11]

Lumbar scoliosis in children

In order to determine the symptoms of the development of lumbar deformity in a child, the parents themselves can perform a small diagnostic test. The child is offered to stand up straight, relax the muscles, and lower his arms freely along the body. Attention should be paid to the uniformity of the protrusion of the clavicles, shoulder blades, to the uniformity of the shoulder height. At the next stage, the child may have a torso skew, especially noticeable when bending forward. With a large curvature, the curve of the arch of the spine becomes visible to the naked eye.

In the early stages of pathology, outwardly, the problem practically does not appear: the diagnosis is made by a specialist, based on X-rays.

Scoliosis is found in children quite often. And there are a number of explanations for this. First, the child's body is rapidly growing and developing, and many organs and systems do not always have time to "catch up" in the development of neighboring structures. It is with such a confluence of events that a fertile soil is created for the emergence of a curvature of the spine. The rapid growth of bone structures against the background of a slow build-up of the ligamentous-muscular apparatus leads to a disproportionate load on the spine. As a consequence, the appearance of deformation. [12]

Another factor influencing the occurrence of the problem is the increased stress on the still fragile spine. Young schoolchildren are forced to wear fairly heavy schoolbags and backpacks, and sit at a desk for a long time (not always functional and comfortable). All these reasons can be leveled if you pay attention to them in a timely manner.

Stages

The clinical picture in lumbar scoliosis depends on the stage of the disorder. So, 4 degrees of development of pathology are known, the main criterion of which is the angle of deformity.

• Grade 1 lumbar scoliosis is often asymptomatic. Discomfort can be expressed in recurrent headaches, general weakness, back fatigue, and slight back pain (especially after routine work). Outwardly, only a doctor can determine the curvature. In some cases, it becomes necessary to perform an X-ray or MRI.
• Grade 2 lumbar scoliosis is characterized by an apparent deviation angle of 11-25 °. If you ask the patient to lean forward, then you can find a slight asymmetry of the spinal column, a different level of location of the shoulder blades, hips. The patient complains of pain when trying to rotate the trunk.
• Grade 3 lumbar scoliosis is characterized by the appearance of a curvature arch in the range of 26-50 °. The external manifestation of deformity is clear, a pronounced rib hump becomes noticeable. The patient complains of regular pain and limited mobility.
• Grade 4 lumbar scoliosis is accompanied by an increase in the deformed arch of more than 50 °. We are talking about a neglected curvature of the spinal column.

Forms

Doctors identify the following variations of lumbar scoliosis:

• Idiopathic scoliosis of the lumbar spine is a curvature, the cause of which cannot be found out. According to statistics, such deformations are 80% of all detected.
• Dysplastic lumbar scoliosis is the most severe variant of the course of deformity due to congenital developmental pathology of the corresponding spine. The disease is associated with a violation of metabolic processes and blood supply to the tissues of the vertebrae and discs.
• Degenerative scoliosis of the lumbar spine is a pathology caused by degenerative-dystrophic lesions, osteoporosis (loss of bone mass), osteomalacia (bone softening). This kind of pathology is more typical for people over 40-45 years old. [13]
• Thoracolumbar scoliosis is a curvature with its apex at the level of the Th11-Th12 vertebrae.
• Lumbosacral scoliosis is a curvature with an apex at the L5-S1 level of the vertebrae.
• Lumbar C-shaped scoliosis is a deformity with one curvature arch with an apex at the level of L1-L2 vertebrae.
• Left-sided lumbar scoliosis is more typical for left-handers: anatomical disorders of the vertebrae and the supporting mechanism to the left side are noted. Accordingly, the curvature arc is retracted to the left, which becomes noticeable upon external examination.
• Right-sided lumbar scoliosis is accompanied by a deviation of the spinal column (vertebrae and supporting structures) to the right side. Right-sided curvature is more common than left-sided.

Complications and consequences

Lumbar scoliosis can cause a host of internal complications. This is due, in particular, to a change in the location of certain organs from the deformed side. The most commonly affected urinary, digestive, reproductive system, as well as blood circulation.

Already some time after the formation of a scoliotic arch in the human body, the risk of developing irreversible changes in the cardiovascular apparatus increases significantly. The arterial blood flow does not receive enough oxygen, the internal size of some heart chambers increases, and a condition similar in symptomatology to pulmonary heart disease occurs. Even after the correction of scoliotic deformity, the indicators of cardiac activity no longer return to normal. And such a consequence is far from the only one. [14]Among the most common complications:

• chronic pain syndrome;
• disorders of the digestive system and genitourinary system, systematic intestinal flatulence, constipation;
• infertility in women, congestion in the pelvic area;
• nervous pinching, paresis and paralysis;
• the development of cascading fractures; [15]
• swelling of the lower extremities;
• weakening of the muscle tone of the abdominal wall;
• psychological disorders, depression, neuroses caused by defects in appearance.

As a result of the compression of blood vessels against the background of vertebral artery syndrome, cerebral blood supply deteriorates, which in childhood is manifested by impaired memory and thought processes. Children have learning difficulties. [16]

In adolescence, neurological symptoms are often found.

Can lumbar scoliosis disappear in a child?

The curvature can be corrected at an early stage if you follow the simple recommendations of specialists. For example, it is important to explain to the child how important it is to take breaks from work, and during recess not to stay at the desk, but to stand up, walk or run, stretch, and make several bends with the body. Even a couple of exercises will help keep your back muscles in good shape.

Another important condition is not to carry a briefcase or backpack, but a special knapsack with an orthopedic back. All accessories in it should be stacked evenly and neatly, and not chaotically. Overloading the back should be avoided, but it is also not recommended to carry a briefcase in your hands or on one shoulder: this can aggravate the skew of the spine.

The sooner measures are taken to eliminate the deformation, the greater the chances of a cure. Additionally, it is imperative to connect manual therapy and therapeutic exercises. Only in this case, you can count on the correction of the pathology. [17]

Lumbar scoliosis hernias

A hernia is a kind of extrusion of the intervertebral disc outside the fibrous ring as a result of its rupture. The spinal column, weakened by curvature, often acquires such hernias, and this complication is difficult to avoid. [18]

A hernia with lumbar scoliosis has its own characteristics: the protrusion is directed into the intervertebral canal, presses down on the nerve ending, and an acute pain syndrome develops. In such a situation, it is not enough just to relieve the pain. Against the background of curvature, the hernia will continue to increase, so the symptoms will again make themselves felt, and the clinical picture will become more diverse:

• severe pain will appear due to extensive irritation of the nerve fibers;
• the lower extremities will regularly go numb, up to the development of tissue dystrophy;
• swelling, fatigue in the legs, pain will disturb;
• the performance of the digestive tract (in particular, the intestines) and the urinary system will be disrupted.

Both scoliosis and hernia are curable conditions provided that they are diagnosed in a timely manner and treated appropriately. But neglected cases are already difficult to treat or are not treated at all, the patient becomes disabled. [19]

Sacralization of the lumbar spine in scoliosis

Sacralization is a congenital defect of the spinal column in which the fifth lumbar vertebra is to some extent attached to the sacrum. This pathology often accelerates the development of osteochondrosis or spondyloarthrosis. [20]

Sacralization is accompanied by an increase in pressure on the lumbar segments, which are located above the fusion site. Under the usual average load, the spinal column copes with its tasks, however, with an increase in pressure on the vertebrae (for example, with lumbar scoliosis), a congenital disorder makes itself felt.

Pathology can manifest itself on the right, left, or on both sides of the vertebra. Partial fusion is observed with cartilaginous and articular forms of the disease, and complete fusion occurs with bone sacralization. [21]

Severe clinical symptoms in scoliosis with sacralization are rarely observed, the general well-being of the patient practically does not suffer. If there are manifestations, then the only method of treatment is surgery, although in practice the surgeon is rarely asked for help.

Diagnostics of the lumbar scoliosis

In the process of diagnostic measures, the doctor listens to the patient's complaints. In particular, it draws attention to the presence of pain along the spinal column, a feeling of fatigue in the back, muscle weakness, and poor posture. The anamnesis should include information about the time of the appearance of the first signs of a disorder, about the transferred pathologies, about complaints during periods of intensive growth of the child.

On examination, the doctor draws attention to posture disorders, curvature of the spinal column, asymmetry of the shoulder girdle, angles of the shoulder blades, waist triangles and the axis of the iliac bones, as well as the presence of a rib hump.

Palpation is determined by the presence of pain along the spine.

Laboratory tests are nonspecific, but can be prescribed as part of general research. In some cases, a clinical, biochemical blood test is required with an assessment of the level of phosphorus and calcium, as well as a clinical analysis of urine.

Instrumental diagnostics includes X-ray of the spine in two projections (regardless of the form of deformity), functional X-ray of the thoracolumbar spine with left and right tilt (especially important for idiopathic scoliosis). Additionally, magnetic resonance imaging of the spinal column is prescribed - to exclude syringomyelitis cystic formations, hemivertebrae, spinal disorders, diastometamielia. Computed tomography of the spine is performed to exclude synostosis of the vertebral bodies, additional hemivertebrae. [22]

Differential diagnosis

Differential diagnosis is carried out in the presence of the corresponding symptoms:

• If postural disorder, rib hump, motor restrictions are present against the background of a negative Mantoux reaction, then the pathology is differentiated with other types of scoliosis.
• If there is a reference to spinal injuries, kyphosis without restriction of mobility with a negative Mantoux test, then the pathology is differentiated from juvenile kyphosis - Scheuermann-Mau disease.
• In the presence of a primary tuberculous focus, a positive Mantoux reaction and limited motor activity, the pathology is differentiated from tuberculosis of the spine.

Treatment of the lumbar scoliosis

Depending on the severity of the pathological deformity and the patient's age, the doctor may prescribe either conservative (in most cases) or surgical treatment of lumbar scoliosis .

Prevention

In most cases, lumbar scoliosis begins to develop during early school age. The most common causes: improper posture, weakness of the muscular corset and ligamentous apparatus - especially in children who do not play sports and do not have the opportunity to additionally strengthen their back muscles. Both at school and at home, the child sits at the table for a long time, not observing the posture, so most schoolchildren acquire scoliosis already in primary school.

In order to avoid the development of this disorder, it is necessary from early childhood to teach the baby to the correct posture, to evenly distribute the load on the back. Exercise is an important preventive step. It is good if the child regularly visits the sports section, or does morning exercises every day. Enough simple exercises that work out the thoracic, lumbar and cervical spine.

Another important preventive condition is wearing a comfortable knapsack (not a briefcase or a backpack, but a knapsack with a rigid back). Unilateral shoulder bags are especially not recommended. It is also necessary to monitor the student's gait, to prevent stoop.

All of the above tips are also relevant in relation to adults, and not only in terms of prevention, but also to prevent further aggravation of an existing curvature.

Among sports, swimming is considered to be the most beneficial for the back. This is both a pleasant pastime and a great way to relieve excess stress on the spinal column. It is advisable to study with an instructor. Thanks to regular training, there is a strengthening of the muscles of the back, straightening of scoliosis in the early stages of development. A good effect is noted from doing water aerobics, which strengthens the body and, at the same time, practically does not differ in increased injuries.

Forecast

If we neglect the main preventive and therapeutic recommendations, then the curvature of the spinal column in most cases progresses, accompanied by a violation of the normal interposition of internal organs. The appearance of physical inferiority, disorders of blood supply as a result of displacement of the vascular network, neurological disorders due to infringement of nerve fibers and endings, functional problems from the liver, kidneys, pancreas, reproductive system.

Cosmetic curvature defects negatively affect the psyche, which can provoke serious suffering for the patient, up to the development of depressive conditions, neuroses and psychosis. Nevertheless, lumbar scoliosis, detected at the initial stages of development in childhood, lends itself well to correction and can be corrected in a relatively short time, provided that all medical recommendations are followed.