Scoliosis treatment

According to modern concepts, prevention of idiopathic scoliosis is practically impossible due to the lack of a generally accepted and evidence-based theory of its origin, therefore, treatment of scoliosis requires timeliness.

The only thing we can talk about is preventing the development of severe forms of the disease. For this purpose, it is necessary to conduct universal screening examinations of preschool and school-age children. The best method is recognized as the KOMOT method, the equipment for which has been developed in both stationary and mobile versions. During the screening examination, several groups of children are identified.

• The first of these are healthy children who only need routine preventive examinations.
• The second group is children who have a clear violation of the relief of the dorsal surface of the body. They need a targeted examination by an orthopedist, as well as spondylography in a standing position. Spondylography data allows us to identify three subgroups of patients who need different treatment tactics.
• Patients with deformities less than 20° require dynamic observation by an orthopedist until they reach the age of completion of skeletal formation with periodic (once every 6 months) control spondylography.
• For deformations from 20 to 40°, complex conservative treatment of scoliosis is indicated.
• Scoliosis with a Cobb angle of more than 40° is considered an indication for surgical intervention.

Conservative treatment of scoliosis

If the initial scoliotic arc of less than 20° progresses, the patient moves to the second subgroup, which requires conservative treatment. Today, the optimal treatment for scoliosis in such patients is considered to be in a specialized boarding school, where children are under constant supervision of an orthopedist and receive complex therapy, traditionally including an orthopedic regimen with unloading the spine during school hours, corrective and general therapeutic exercise, massage, swimming, physiotherapy, and psychological relief. It is important to emphasize that the use of techniques from the arsenal of manual medicine or other similar ones to correct the shape of the spinal column is strictly contraindicated for any type of spinal deformity.

The boarding school should be equipped with a computer tomography unit, which allows reducing the radiation load during control examinations. In the presence of documented progression of scoliotic deformation, corset therapy is indicated using corrective (not fixing!) corsets, allowing active influence on the deformed spine. Corset therapy, which provides for constant monitoring of the state of the corset and corrective efforts, is also carried out in the conditions of a specialized and boarding school. If complex conservative treatment of scoliosis is unsuccessful due to high potential for deformation progression, the value of which exceeds 40 ° according to Cobb, it is necessary to consider the issue of the patient's period in a vertebrological clinic for surgical treatment.

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Corset therapy for idiopathic scoliosis

When developing principles for constructing prosthetic and orthopedic devices for treating patients with scoliosis, the greatest interest is in understanding the biomechanical patterns that determine the maintenance of the vertical position of the body.

In idiopathic scoliosis, the body mass, which creates a static moment in the frontal plane, is opposed not by the same, but by different efforts of the paravertebral muscles. Consequently, a patient with scoliosis is characterized by an asymmetrical action of the body mass and a one-sided antigravity work of his muscles and ligaments.

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Basic principles of corset construction

First, scoliosis treatment should provide for a reduction in the deforming effect of body weight. The static moment of body weight can be reduced by external supports, through which part of the body weight is transferred directly to the pelvis. This principle of constructing corsets has been known for a long time. But a noticeable unloading effect was achieved with the introduction of a head holder connected by longitudinal splints to the pelvic sleeve. Examples include the Milwaukee corset and the TsNIIPP corset.

The second way to reduce the deforming effect of body weight is to bring the line along which the body weight exerts a load closer to the curved section of the spine. This is achieved by changing the relationship of the parts of the body in the corset. When the patient maintains the corrected posture, the static moment of the body weight decreases, which entails a decrease in the antigravity efforts of the paravertebral muscles. As a result, the pressure on the vertebrae decreases.

Most of the corsets used today are equipped with transversely located splints. Three horizontal forces act on the body from these splints. One of them acts on the body in the area of the apex of the curvature, the other two are directed in the opposite direction, they are applied above and below the area of the curvature.

Thus, there are several basic biomechanical principles for constructing corsets: unloading the spine, correcting curvature, maintaining maximum torso movement, and actively maintaining posture in the corset.

Most modern corset designs combine various effects on the spine. However, the greatest importance is given to those that ensure active muscle activity in the corset.

Among the widely used systems are the Milwaukee corset, the Boston corset system, the Stagnfra corset, the Shede group of orthopedic devices, and the TsNIIPP corsets.

The standard program of wearing a corset for idiopathic scoliosis is 23 hours a day, in reality very few adolescent patients agree to this program. Partial corset wearing programs can be more effective than full corset wearing programs. In practice, this is done as follows: full corset wearing for approximately 9 months (or with initial correction - 90%) - for 6 months. If at this time all factors are favorable, the patient is allowed to finish the corset program with wearing the corset for 16-18 hours a day.

Another type of partial corset wearing program is only during night sleep. For this purpose, the thoracolumbar-sacral orthopedic device "Charleston" was developed in the mid-1980s. The initial results of using this device are comparable to the results of using other low-profile orthopedic devices.

All existing corset therapy programs remain imperfect because they cannot eliminate the cause of the disease, but only affect some of its mechanical manifestations.

It is possible to speak about the successful result of corset treatment only after a long time (on average 5 years) has passed since the end of corset use, if this result is achieved in patients with a risk of significant progression of the arc and if after the end of corset effect the magnitude of the scoliotic arc is not greater than before the start of treatment.

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Surgical treatment of scoliosis

History of scoliosis treatment

The history of scoliosis treatment is much longer than the history of orthopedics. The Howard Smith papyrus (2500 BC) describes the diseases and injuries of the builders of the Egyptian pyramids. Even then, in ancient times, there were references to spinal deformities and their incurability. Hippocrates (460-370 BC) formulated the principles of correction used for many centuries after him: transverse compression on the top of the hump in combination with longitudinal traction. Galen (131-201) introduced into practice the terms "scoliosis", "kyphosis", "lordosis", "strophosis" (rotation of the scoliotic spine). In the Asclepion in Pergamon, where he worked, they tried to correct spinal deformities with active and passive exercises, including breathing exercises. These were the first steps in the use of therapeutic gymnastics. Medieval physicians did not make any significant changes to this approach.

Ambroise Pare (1510-1590) was the first to describe congenital scoliosis and came to the conclusion that spinal cord compression was the cause of paraplegia. He used metal corsets to correct spinal deformities. Such corsets were described by the author in 1575.

The royal consultant and dean of the Paris medical faculty Nicolas Andry (1658-1742) shared the opinion of Hippocrates and claimed that a special table was needed for proper stretching of the spine. Corsets, which were an integral part of the toilet of young ladies, according to Andry's advice, should be changed as the patient grew.

Swiss physician Jean-Andre Venel (1740-1791), an obstetrician and orthopedist, founded the world's first orthopedic clinic in 1780 in the city of Orbes (Switzerland).

At the beginning of the 19th century, almost all famous surgeons were involved in the treatment of scoliosis. Those interested in orthopedics, but prosthetists and engineers achieved particular success. At THIS time, brothers Timothy and William Sheldrake gained great fame in England, who introduced corsets with springs into practice.

In the 19th century, corrective gymnastics for the treatment of scoliosis became widespread, especially in Germany. The Swede Peter Henrik Ling (1776 - 1839) created a system of exercises known as "Swedish gymnastics".

At the same time, the development of surgical treatment of scoliosis began. The French anatomist and surgeon Henri-Victor Bouvii (1799 - 1877) in 1835, in Paris, performed the first myotomy for the correction of scoliosis.

In 1865, the English physician W. Adams described in his lecture the tendency for the vertebrae to rotate, leading to the formation of a rib hump in structural scoliosis. This diagnostic approach still bears his name.

Another significant contribution to the problem of scoliosis treatment was made by the Englishman J. W. Sayre (1877), who used corrective plaster corsets, which had previously been used only for Pott's disease.

The discovery of X-rays played a huge role in the study of spinal deformities.

At the end of the 19th century, surgical methods for treating scoliosis appeared, which are still used in their pure form or in modifications. The famous German surgeon Richard von Volkmarm (1830-1889) performed the first thoracoplasty. In Russia, the first thoracoplasty for a costal hump was performed by R. P. Vreden, who had observations of 15 patients by 1924.

Fritz Lange (1864-1952) - the author of the method of stabilizing the spine in tuberculous spondylitis with metal wires that fixed the spinous processes. Probably, this was the first experience of metal implantation in vertebrology.

Modern surgical treatment of scoliosis began shortly before the First World War. The absolute priority belongs to the American surgeon Russel Hibbs (1869-1932). In 1911, he reported on three cases of tuberculosis treated with spondylodesis, and then proposed using this method for scoliosis. This he did in 1914, and in 1931 he published the results of spondylodesis in 360 patients.

Another American, John Cobb (1903-1967), invented a method of measuring scoliotic curvature on an X-ray, which is still used today. Cobb was one of those who actively introduced methods of surgical treatment of scoliosis. In 1952, he published the results of dorsal spondylodesis in 672 patients over a period of more than 15 years.

At the beginning of World War II, the American Orthopedic Association issued a committee headed by Shands, which set the goal of investigating the state of the scoliosis problem and determining the most effective treatment method. This committee in 1941 came to the following conclusions.

The main complaint of patients is related to a cosmetic defect. Conservative treatment of scoliosis prevents progression of scoliosis in 40% of patients, in the remaining 60% of patients the deformation progresses.

Corrective treatment of scoliosis using traction and corsets without spondylodesis is ineffective.

Self-correction of curvature after spondylodesis provides a chance to maintain the correction and a positive outcome,

After this report, surgical treatment of scoliosis became the only option. Direct traction on the spine using a halo device was proposed by Nickel and Rep in 1959. This device also found application in preoperative preparation of patients with scoliosis and kyphosis.

A major contribution to the development of scoliosis surgery was made by American orthopedist John Moe. In 1958, he published the results of dorsal spondylodesis in 266 patients. In this work, Moe emphasized the need for careful destruction of the facet joints along the spondylodesis zone with the placement of additional grafts in the defect area. This technique allowed to reduce the number of unsuccessful outcomes from 65 to 14%,

In 1955, the first epiphysiospondylodesis operation was performed by the famous English orthopedist R. Roaf. He attempted to limit the growth of the vertebrae and the height on the convex side of the deformity and thereby achieve self-correction of the curvature during the patient's further growth.

The founder of Russian vertebrology Ya.L. Tsivyan in 1961 was the first to use ventral spondylodesis (auto- or allobone) for scoliosis. The goal of the operation is to limit the ongoing torsion of the vertebrae, and therefore the progression of the deformation. The surgical intervention is based on the idea of the great Russian orthopedist V.D. Chaklin.

The idea of internal metal correction was brewing, flying in the air. It is necessary to mention the development of Allan, who proposed a kind of jack made of two Y-shaped supports, which were installed on the transverse processes of the end vertebrae on the concave side of the deformation and connected by a hollow cylindrical rod (later improved by A.V. Kazmin); endocorrectors Wejsflog (1960) and Wenger (1961), spring endocorrector A. Gruca (1958). All these devices are now of only historical interest. The first spinal instrumentation, still used and regarded as the gold standard in surgical treatment of scoliosis, is the brainchild of Paul Kandall Harrington (Houston, Texas).

Scoliosis Treatment and CDI Technique in Special Cases

Severe rigid thoracic and thoracolumbar scoliosis

This group should include scoliotic deformations of approximately 75-90° according to Cobb. With such deformations, the derotation maneuver is either ineffective or practically impossible to implement due to gross torsional changes at the apex of the primary arc of curvature. In this regard, the authors of the method proposed a technique called three-rod.

The two rods on the concave side are of unequal length. One is between the end vertebrae of the arch (long), the other is between the intermediate vertebrae (short). The short rod, 6-8 cm long, is inserted first. The long rod is pre-bent to match the normal sagittal profile of the thoracic and lumbar spine. Distraction forces are applied to both rods. Then, two DTT rods are tied and pulled toward each other to reduce the angle of deformation. The rod on the convex side, pre-bent, is inserted in compression on hooks as described above. At the end of the operation, the long rods are tied with two more DTT rods.

In cases where spondylograms with lateral tilt demonstrate extreme rigidity of the deformity, it is necessary to perform a preparatory intervention aimed at mobilizing the spine. This may consist of excision of the intervertebral discs along the main arc of curvature and/or dorsal mobilization (dissection of the ligamentous apparatus, resection of the articular processes). Both operations (mobilization and correction with CDI instrumentation) are performed in one stage.

Double chest deformities

The problem is that both arcs need to be corrected with the restoration of the entire thoracic kyphosis. Therefore, the rod cannot be rotated on both arcs and in one direction. There are two ways to solve this problem.

• The first way is to place hooks and a rod on the concave side of the lower thoracic curve in the usual way for rotation and kyphosis formation, as in typical thoracic deformities. Then a rod is implanted on the concave side of the upper curve to restore kyphosis by derotation, but this rod must be long to be able to capture the convex side of the lower curve, and at this level the rod must push neutrally on the apex of the lower curve to enhance derotation. A hook is placed on the lower end vertebra of the convex side of the lower curve, which naturally works on compression. Finally, a short rod is implanted on the convex side of the upper curve, connected to the one located along the concavity of the lower soul, with a connector.
• The second way is to use two long rods, curved according to the required sagittal contour of the spine and insert them sequentially into the hooks, applying only traction and pressure, but not derotation. The correction will be obtained only along the axis of both rods.

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Lumbar kyphoscoliosis

To restore or maintain the normal sagittal contour of the lumbar spine, it is necessary to bring the semi-arches of the vertebrae together, and therefore any distracting force applied to the concave side of the deformity will be harmful. To achieve the desired result, correction is carried out by applying compression along the convex side of the arch. The first rod is inserted into the hooks on the convex side of the arch, first bent in accordance with the normal lumbar lordosis, and then rotated so that the apex of the lumbar arch shifts ventrally and toward the midline. This achieves multiplane correction. Many surgeons prefer to use pedicle screws in the scissor spine instead of hooks - at the apex of the arch or in the area of the end vertebra. This provides a greater degree of correction and more reliably fixes the resulting effect.

A second rod, less curved than the first, is implanted on the concave side of the curvature in distraction mode. It should increase the opening of the concave side and slightly increase derotation by displacing the apical vertebra in the dorsal direction. The design is completed by installing two DTTs.

Launched deformations

This category includes deformations greater than 90°. Such deformations are usually the result of malignant progression of juvenile and infantile scoliosis that has not been treated or has been treated inadequately (for example, by manual therapy methods). Quite often, the magnitude of these deformations reaches 130° -150° according to Cobb, which is accompanied by a gross distortion of the shape of the body. The rib cage shifts toward the convexity of the scoliotic arc and distally in such a way that the lower ribs are immersed in the cavity of the large pelvis. Deformation of the skeleton inevitably affects the functions of internal organs (primarily, the heart and lungs).

Additional mobilization of the most structurally altered part of the arch in the form of excision of 4-6 intervertebral discs allows to obtain with the help of CDI a very significant correction of both the deformation itself and the balance of the body, significantly reducing the cosmetic defect. It is advisable to perform both interventions under the same anesthesia. Initially, discectomy and ventral interbody spondylodesis are performed from the ventral approach, for which it is optimal to use autografts from the resected rib. Then, the deformation is corrected with CDI instrumentation and dorsal spondylodesis with autobone. In cases of advanced deformations, the formation of the upper and lower hooks is extremely important, each of which should include at least four hooks. The apical and intermediate hooks play a slightly smaller role, especially since their installation can be complicated by anatomical changes characteristic of extreme torsion.

A somewhat more radical treatment of scoliosis with the most severe spinal deformities is used by Tokunaga et al. During the ventral intervention, the spongy bone of the vertebral bodies at the apex of the deformity and the corresponding intervertebral discs are completely removed. As a result, a significant cavity is formed, the walls of which are represented by the endplates of the vertebral bodies. Autobone is placed in it - the removed spongy bone and fragments of the resected rib. This technique, according to the authors, allows for a greater degree of spinal mobility, and subsequently - a reliable bone block along the arc of curvature.