Scoliosis treatment

According to modern ideas, the prevention of idiopathic scoliosis is practically impossible due to the lack of a generally accepted and evident theory of its origin, so the treatment of scoliosis requires timeliness.

It can only be about preventing the development of severe forms of the disease. To this end, it is necessary to carry out screening screening of children of preschool and school age. The best is the method of KOMOT, the equipment for which is developed in both stationary and mobile versions. During the screening survey, several groups of children are identified.

• The first of these is healthy children, who need only routine preventive examinations.
• The second - children, who showed a distinct violation of the relief of the dorsal surface of the trunk. They need a focused examination of the orthopedist, as well as spondylography in a standing position. The data of spondylography make it possible to distinguish three subgroups of patients who need and various therapeutic tactics.
• Patients with deformities less than 20 ° need a dynamic observation of the orthopedist until the age of completion of the formation of the skeleton with periodic (1 every 6 months) control spondylography.
• With a deformation of 20 to 40 degrees, 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 arch is less than 20 °, the patient passes over the second subgroup requiring conservative treatment. To date, optimal treatment of scoliosis in such patients is considered optimal in conditions of a specialized boarding school, where children are under the constant supervision of an orthopedist and receive a complex therapy, traditionally including orthopedic regimen with unloading of the spine and the course of training sessions, corrective and general therapeutic physical training, massage, swimming , physiotherapy, psychological discharge. It is important to emphasize that the use of manual medicine or other similar to them to correct the shape of the spine is categorically contraindicated in any type of deformity of the spine.

The boarding school should be equipped with an installation for computed tomography, which allows to reduce the radiation load during the control examinations. In the presence of documented progression of scoliotic deformity, corset therapy is shown with the use of corrective (not fixing!) Corsets, which allow to actively influence the deformed spine. Corsetotherapy, which provides for constant monitoring of the condition of the corset and corrective efforts, is also conducted in a specialized and boarding school. If the complex conservative treatment of scoliosis is unsuccessful due to the high potency of the deformation progression, the value of which exceeds 40 ° Cobb, it is necessary to consider the issue of the patient's period in the vertebrological clinic for surgical treatment.

[1], [2], [3], [4]

Corsetotherapy of idiopathic scoliosis

When developing the principles of building prosthetic and orthopedic means for the treatment of scoliosis patients, the greatest interest is in understanding the biomechanical regularities that determine the preservation of the vertical position of the trunk.

With idiopathic scoliosis, the mass of the body, creating a static moment in the frontal plane, is opposed by not identical, but different efforts of the paravertebral muscles. Consequently, the patient is characterized by scoliosis asymmetric action of body weight and unilateral antigravitational work of his muscles and ligaments.

[5], [6], [7]

Basic principles of building corsets

First - the treatment of scoliosis should provide for a reduction in the deforming effect of body weight. The static mass moment of a body can be reduced by means of external supports, along which a part of the body mass is transmitted directly to the pelvis. This principle of building corsets was known for a long time. But a noticeable unloading effect was achieved with the insertion of a head restraint connected by longitudinal tires to the pelvis. Examples include the Milwaukee corset and the CSRPP corset.

The second way is to reduce the deforming influence of the body weight - the approach of the line, along which the weight of the body weighs, to the curved part of the spine. This is achieved by changing the relationship of the trunk parts in the corset. If the patient retains the corrected posture, the static mass moment of the body decreases, which entails a decrease in the antigravitational forces of the paravertebral muscles. As a result, pressure on the vertebrae decreases.

Most of the corsets currently used are equipped with transversely arranged tires. On the side of these tires, three horizontal forces act on the trunk. One of them acts on the trunk in the region of the top of the curvature, the other two are directed in the opposite direction, they are applied above and below the section of the curvature.

Thus, there are several basic biomechanical principles for constructing corsets: unloading the spine, correcting the curvature, retaining the maximum movements of the trunk, actively holding the pose in the corset.

Most modern corset designs combine various effects on the spine. However, the greatest importance is attached to those of them that provide active muscle activity in the corset.

Milwaukee corset is one of the most widespread systems. Boston corset system, Stagnfra corset, Shede orthopedic device group, CSRIIRP corsets.

The standard program of wearing a corset for idiopathic scoliosis is 23 hours a day, really very few teenage patients agree to this program. Programs of partial wearing of a corset can be more effective than programs for full wearing of a corset. Practically it is carried out in the following way: full wearing of the corset for about 9 months (or with an initial correction of 90%) - for 6 months. If at this time all factors are favorable, the patient is allowed to complete the corset program with wearing a corset for 16-18 hours a day.

Another type of program for wearing a corset is only during a night's sleep. To this end, in the mid-1980s, the chest-lumbosacral and orthopedic apparatus Charleston was developed. Initial results of using this device are comparable with the results of using other low-profile orthopedic devices.

All existing programs for corsetotherapy remain imperfect, because they can not influence the elimination of the cause of the disease, but only affect some of its mechanical manifestations.

Talk about the successful outcome of corset treatment can be only after a long time (an average of 5 years) after the end of the application of the corset. If this result is reached in patients at risk of significant progression of the arch and if, at the end of the corset impact, the magnitude of the scoliotic arch is not greater than before the start of treatment.

[8], [9], [10]

Surgical treatment of scoliosis

History of Scoliosis Treatment

The history of scoliosis treatment is much longer than the history of orthopedics. In the papyrus of Howard Smith (2500 BC), the diseases and injuries of the builders of the Egyptian pyramids are described. Back then, in ancient times, there were references to vertebral deformations and their incurableness. Hippocrates (460-370 BC) formulated the principles of correction, applied for many centuries after it: transverse compression on the top of the hump in combination with longitudinal traction. Galen (131-201) introduced the terms "scoliosis", "kyphosis", "lordosis", "strophosis" (rotation of the scoliotic spine) into practice. In Asklepion on Pergamon, where he worked, they tried to correct the deformities of the spine with active and passive exercises, including respiratory gymnastics. These were the first steps in the application of medical gymnastics. Doctors of the Middle Ages did not make significant changes in this approach.

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

Royal consultant and dean of the Paris School of Medicine Nicolas Andry (1658-1742) shared the opinion of Hippocrates and argued that a proper spinal table needed a proper spinal stretching. Corsets, which were an integral part of the toilet of young ladies, on the advice of Andry should be changed as the patient grows.

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

At the beginning of the XIX century, almost all known surgeons were engaged in the treatment of scoliosis. Interested in orthopedics, but special successes were achieved by prosthetists and engineers. In this era, the brothers Timothy and William Sheldrake became more famous in England, who introduced corsets with springs into practice.

In the XIX century, widespread, especially in Germany, received corrective gymnastics in the treatment of scoliosis. Swede Peter Henrik Ling (1776 - 1839) created an exercise system known as the "Swedish gymnastics".

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

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

Another important contribution to the problem of scoliosis treatment was made by the Englishman J. W, Sayre (1877), who applied corrective gypsum corsets previously used only with Pott's disease.

A giant role in the study of deformations of the spine was played by the discovery of X-rays.

At the end of the nineteenth century, surgical methods for the treatment of scoliosis appeared, which are still used in pure form or in modifications. The famous German hippy Richard von Volkmarm (1830-1889) produced the first thoracoplasty. In Russia, the first thoracoplasty for the rib hump was performed by PP Vreden, who had by 1924 observations of 15 patients.

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

Modern surgical treatment of scoliosis began not long before the First World War. Absolute priority belongs to the American surgeon Russel Hibbs (1869-1932). In 1911, he reported on three cases of tuberculosis, treated with a glandular, and then suggested using this method in scoliosis. Which was carried out in 1914, and in 1931 published the results of spondylodesis in 360 patients.

Another American, John Cobb (1903-1967), invented a method for measuring scoliatic curvature on a radiograph, 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 the Second World War, the American Orthopedic Association issued a committee headed by the Shands, which set out to investigate the state of the scoliosis problem and determine the most effective therapeutic method. In 1941, this committee came to the following conclusions.

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

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

Self-correction of curvature after a spondylodease gives chances for retention of correction and a positive outcome,

After this report, operative treatment of scoliosis became uncontested. Direct traction on the spine with the help of a halo was proposed by Nickel and Repu in 1959. This device has found application and preoperative preparation of patients with scoliosis and kyphosis.

A major contribution to the development of scoliosis surgery was made by American orthopedists John Moe. In 1958 he published the results of dorsal spondylodesis in 266 patients. In this work, Moe stressed the need for a thorough destruction of the arcuate joints throughout the area of the spinal fusion with the room and the area of defect of additional grafts. This technique allowed to reduce the number of unsuccessful outcomes from 65 to 14%,

In 1955, for the first time, an operation of epiphysis was performed by the famous English orthopedist R. Rof. He tried to limit the growth of vertebrae and height on the convex side of the deformation and thereby achieve self-correction of curvature in the process of further growth of the patient.

The founder of Russian vertebrology Ya.L. Tsivyan, and in 1961, for the first time, used scoliosis ventral spondylodesis (auto- or allochthy). The purpose of the operation is to limit the continuing torsion of the vertebrae, and hence the progression of the deformity. The operative intervention is based on the idea of the great Russian orthopedist V.D. Chaklin.

Ideas of internal metal correction were brewing, flying in the air. It is worth mentioning the development of Allan, which proposed a kind of jack of two Y-shaped supports that were installed on the transverse processes of the terminal vertebrae on the concave side of the deformation and connected by a hollow cylindrical shaft (further improved by AV Kazmin); endocorrectors Wejsflog (1960) and Wenger (1961), spring endocorrector A. Gruca (1958). All these devices now represent only a historical interest. The first vertebral instrumentation, used so far and regarded as the gold standard for the surgical treatment of scoliosis, is the offspring of Paul Kandall Harrington (Houston, Texas).

Treatment of scoliosis and CDI technique in special cases

Rigid, rigid thoracic and thoracolumbar scoliosis

This group should include scoliotic deformations of about 75-90 ° Cobb. With such deformations, the de-actuating maneuver is either inefficient, or practically impracticable due to gross torsion changes at the apex of the primary arc of the Curvature. In this connection, the authors of the method proposed a technique called a three-rod technique.

Two rods on the concave side - of unequal length. One - between the terminal vertebrae of the arch (long), the second - between the intermediate vertebrae (short). A short rod length of 6-8 cm is set first. The long stem is previously bent according to the normal sagittal profile of the thoracic and lumbar spine. Distraction efforts are applied to both rods. Then, two DTT rods are tied and attracted to each other to reduce the angle of deformation. The stem on the convex side, pre-curved, is set in the hook compression state, as described above. At the end of the operation, the long rods are connected by two more DTTs.

In those cases where spondylograms with a lateral slope show an extreme degree of rigidity of deformation, it is necessary to perform a preparatory intervention aimed at mobilizing the spine. It may consist of excising intervertebral disks during the main arch of curvature and / or dorsal mobilization (dissection of the ligamentous apparatus, resection of the articular processes). Both operations (mobilization and correction by the CDI toolkit) perform one stage.

Double chest deformities

The problem is that it is necessary to correct both arches with restoration of the entire thoracic kyphosis. Therefore, you can not rotate the rod on both arcs and one direction. There are two ways to solve this problem.

• The first way on the concave side of the lower thoracic arch is usually established hooks and a rod for rotation and formation of kyphosis, as in typical chest deformities. The rod is then implanted on the concave side of the upper curvature to restore the kyphosis by deletion, but this rod must be long so that the convex side of the lower curvature can also be grasped, and at this level the rod must push the vertex of the lower arc neutrally to increase rotation. On the lower end vertebrae of the convex side of the lower arch, a hook is mounted, working, naturally, on the compression. Finally, a convex side of the upper curvature is implanted with a short rod connected to the connector, which is located along the concavity of the lower shower.
• The second way is to use two long rods bent in accordance with the necessary sagittal contour of the spine and insert them consistently into the hooks, only applying traction and pressure, but not de-rotation. Correction will be obtained only along the axis of both rods.

[11], [12], [13], [14], [15], [16]

Lumbar cypo scoliosis

To restore or maintain the normal sagittal contour of the lumbar spine, it is necessary to pull together the half-bones of the vertebrae, and therefore any distracting force applied to the concave side of the deformation will be harmful. To achieve the desired result, correction is performed by applying compression on the convex side of the arc. The first rod is inserted into the hooks on the convex side of the arc, it is first bent according to the normal lumbar lordosis, and then rotated so that the vertex of the lumbar arch moves ventrally and to the midline. This is achieved by a microplane correction. Many surgeons prefer to use pediculate screws instead of hooks in the scissor department of the spine - on the top of the arch or in the region of the terminal vertebra. This gives a greater degree of correction and more securely fixes the resulting affect.

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

Running deformations

Deformations of more than 90 ° are referred to this category. Usually such deformations are the result of malignant progression of juvenile and infantile scoliosis that have not been treated or treated inappropriately (for example, by manual therapy). Very often, the magnitude of these deformations reaches 130 ° -150 ° Cobb, which is accompanied by a gross distortion of the shape of the trunk. The thorax is shifted toward the convexity of the scoliotic arch and distally in such a way that the lower ribs sink into the cavity of the large pelvis. Deformation of the skeleton with inevitability affects the functions of internal organons (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 disks allows obtaining by means of CDI a very significant correction of both the deformation proper and the balance of the trunk greatly reduces the cosmetic defect. It is advisable to perform both interventions under the same anesthesia. Initially, ventral access is performed by a discectomy and a ventral interbody fusion, for which it is optimal to use autografts from the resected rib. Correction of deformation by CDI instrumentation and dorsal spondylodesis is then performed by autotension. In cases of neglected deformations, it is extremely important to form the upper and lower grippers, each of which must include a minimum of four hooks. Apical and intermediate hooks play a somewhat smaller role, especially since their setting is difficult with anatomical changes characteristic of the extreme degree of torsion.

A somewhat more radical treatment of scoliosis with the most severe deformities of the spine is used by Tokunaga et al. In the course of the ventral intervention, the spondy bone is completely removed from the vertebral bodies at the apex of the deformity and the corresponding intervertebral discs. As a result, a significant cavity is formed, the walls of which are represented by the end plates of the vertebral bodies. It is placed autosty - a remote spongy bone and fragments of a resected rib. This technique, according to the authors, allows to obtain a greater degree of mobility of the spine, and in the future - a reliable bone block during the arc of curvature.