Thoracic Scoliosis

When the spine in the frontal plane deviates left or right with the simultaneous rotation of the thoracic vertebrae, and this curvature is localized in the thoracic (thoracic) part of the spinal column, chest scoliosis is diagnosed. And such scoliotic deformity is the most common type of scoliosis.

Epidemiology

Congenital scoliosis is detected in one newborn out of 10 thousand.  [1]With imperfect osteogenesis, the incidence of scoliosis in children ranges from 26-74.5%.

In 80-85% of cases, chest scoliosis is idiopathic. [2]Juvenile scoliosis develops at the age of 4–10 years and accounts for 10–15% of all idiopathic scoliosis in children. [3]The prevalence of adolescent idiopathic scoliosis, according to the Journal of Children's Orthopedics, is between 0.5% and 5.2%. 

According to some studies, the detection of asymptomatic breast scoliosis in adults aged 25-65 years is estimated at about 13.4% (with a predominance of women): with a curvature angle of 10-20 ° - 11.6%; with a curvature of 20-30 ° - about 1.6%, and with a Cobb angle of more than 30 ° - within 0.2%. [4]

According to statistics, up to 20% of cases of left-sided thoracic scoliosis are caused by either congenital skeletal abnormalities or neuromuscular pathologies. [5]This deformation can be detected at any age, but most often such scoliosis develops in adolescents (in particular, girls).

Causes of the thoracic scoliosis

In most cases, the causes of scoliosis of the thoracic spine (spina vertebrae thoracicae) are not known. According to experts, it is possible to find out its cause only in 15-20% of cases.

Breast scoliosis in a child can be congenital, although it is more often detected in children aged 10 to 18 years (and to a greater extent it affects girls). The existing congenital form of scoliosis in a baby is the result of abnormalities of the spine that develop in the fetus during pregnancy, and therefore are usually detected at an earlier age than idiopathic scoliosis (with unknown etiology).

More in publications:

• Scoliosis in children
• Congenital scoliosis

Possible causes of the development of breast scoliosis include:

• injuries to the spine or spinal cord;
• infections, in particular, poliovirus, the defeat of which leads to childhood spinal paralysis - polio, as well as some pathogenic bacteria that cause spondylitis;
• birth defects, primarily  spina bifida , hemivertebra,  short neck syndrome , spondylothoracic dysostosis, etc.;
• imperfect osteogenesis  or hereditary skeletal dysplasia (due to mutations in collagen genes);
• Cerebral palsy (cerebral palsy);
• neurofibromatosis ;
• genetically caused damage to the spinal motor neurons - spinal  muscular dystrophy ;
• syringomyelia (bone marrow damage);
• neoplasms of the spine or spinal cord (cysts, tumors).

See also -  Scoliosis: what causes and how to recognize?

Risk factors

Orthopedists draw the attention of patients to such risk factors for the development of thoracic scoliotic curvature, such as:

• family predisposition; [6]
• children's and adolescence (from 10 to 15 years), that is, a period of increased growth of children;
• impaired posture in children , which can lead to postural scoliosis;
• increased chest kyphosis in adolescents with the development of Scheuermann's disease, often accompanied by scoliotic curvature;
• different leg lengths (congenital or acquired);
• dislocations and fractures of the vertebral joints;
• the formation of fibrous (scar) tissue after direct thoracic surgery;
• the presence of rheumatoid arthritis;
• neuromuscular disorders; [7]
• increased doses of ionizing radiation;
• acquired or hereditary metabolic pathologies, for example, type IV mucopolysaccharidosis (Morkio syndrome). See also -  Some diseases accompanied by spinal deformity.
• the presence in the family history of scoliosis or  degenerative-dystrophic diseases of the spine .

Pathogenesis

In vertebrology, the pathogenesis of thoracic scoliosis is considered taking into account the anatomical features of the thoracic scoliosis - the longest part of the spine, which in the lateral projection has a natural bend backwards - kyphosis (with a curvature of 20-45 °). This physiological bend, together with the cervical and lumbar lordosis, ensures the balance of the spinal column.

The thoracic region includes the  thoracic vertebrae  T1-T12, as well as half of the seven dozen faceted (intervertebral) joints of the spine. In addition, there are two dozen bone-transverse joints connecting the thoracic vertebrae T1-T10 with ribs; these joints are formed by the articulation of the transverse processes of the thoracic vertebra and the tubercle of the adjacent rib (each rib has two joints).

In addition, the T1-T10 vertebral bodies on the sides have faces with cartilage-covered depressions (for articulation with the heads of the ribs); Vertebral faces T2-T9 are hemispherical; spinous processes are long and inclined downward. The location of the ribs and spinous processes significantly limits the flexion and extension of the thoracic vertebrae. The greatest rotational ability in the vertebrae is T5-T8.

And fibro-cartilaginous “laying” between the bones - the intervertebral discs of the thoracic part of the spine are the thinnest in the entire spinal column.

What happens with breast scoliosis? A complex deformation of the spine occurs - with lateral curvature relative to its frontal axis and the rotational component in the form of rotation (torsion) of the vertebral joints around their axes. With breast scoliosis in a child, the development mechanism of torsion may be due to the uneven growth of the front and back of the vertebrae; their frontal displacement; pathological changes in the spaces between the vertebral bodies; violation of the centers of ossification on the bodies and processes of the vertebrae (which develop during puberty); insufficient mineralization of bone tissue, etc.

As the state and rotation of the vertebral bodies progresses, a decrease in their height and thickness of the intervertebral discs is observed; vertebral bodies and spinous processes deviate to the concave side of the scoliotic curve, and ribs articulated with them are also directed there, approaching each other. In this case, on the convex side of the large curve, the ribs begin to diverge.

Symptoms of the thoracic scoliosis

The first signs of chest scoliosis begin to manifest a violation of the symmetry of the body, in particular the different heights of the right and left shoulder-scapular regions.

In most cases, patients with adolescent idiopathic thoracic scoliosis do not experience pain. About a quarter of patients with adolescent idiopathic scoliosis have back pain, in particular, pain in the posterior wall of the chest from the side of the rib protrusion. [8] Although pain in thoracic scoliosis can occur with a significant degree of curvature. More information in the article -  Scoliosis as a factor in the development of back pain .

Symptoms of rotational (deforming) scoliosis of the thoracic region include: asymmetry of the shoulders and the entire chest, the formation of a muscle shaft on the back of the neck, protruding shoulder blades or ribs, skew waistline, visual shortening of one lower limb.

See also -  Symptoms of scoliosis

Stages

The degrees of scoliosis of the thoracic region are determined by x-ray: a special markup is made on the x-ray of the thoracic part of the spinal column according to the method of the American orthopedic surgeon John Robert Cobb (1903-1967), and then the angle of curvature is measured - the Cobb angle. [9],  [10], [11]

Slight curvature - chest scoliosis of the 1st degree - is fixed at a Cobb angle of not more than 10 °.

Thoracic scoliosis of the 2nd degree is determined when the angle of curvature is 10-25 °; at an angle of 25-40 (50) °, scoliosis of the thoracic spine of 3 degrees is diagnosed, and if the angle is greater than 40 (50) °, then this is scoliosis of 4 degrees.

There are three stages in the evolution of thoracic idiopathic scoliosis: the primary period of progression, the secondary period of progression and the stable period. The chronology of these different periods is not the same. With “infantile scoliosis”, the main period of an accelerated increase in the curve begins until the age of 6. With "juvenile-sexually mature scoliosis," it occurs between the ages of 6 years and the first stages of puberty, and with "sexually mature scoliosis," the main increase occurs during puberty or adolescence. [12]

Forms

Various forms, types or types of scoliosis of the thoracic spine are distinguished, which are classified by such parameters as anatomical features of curvature, causes, age, etc. (therefore there are several such classifications, which creates certain difficulties with the terminology).

Left-sided thoracic scoliosis is determined by bending to the left: it can be congenital or secondary to various disorders of muscles and tissues, for example, muscular dystrophy or growth of a spinal cord tumor.

Thoracic right-sided scoliosis or right-sided scoliosis of the thoracic spine is determined when the primary curvature arch is formed to the right of the vertical axis of the spine and, depending on the severity, gives the spine the shape of the letter “C” or “S”.

S-shaped chest scoliosis has an additional bend in the opposite direction, which occurs as a result of the body's attempt to compensate for the anomaly. It is usually diagnosed in children or adolescents aged 10 to 15 years - during the period of the first growth spurt; in adults,  S-shaped scoliosis  may be due to various disorders of the muscles or connective tissue.

Idiopathic thoracic scoliosis means that the cause of its development is unknown. This is the most common form of scoliosis in adolescents: adolescent idiopathic scoliosis affects up to four out of a hundred children over ten years of age.

Dysplastic thoracic scoliosis - with an apex of scoliotic curvature in the T5-T9 vertebrae - develops in the presence of congenital anomalies in the formation of structures of the thoracic spine: structural disorders of the vertebral bodies (with the development of asymmetric or sphenoid vertebrae), defects of their spinous processes (underdevelopment or hypertrophy), interplasia dysplasia drives. Such scoliosis can be called congenital or idiopathic dysplastic, since the etiology of a significant part of the abnormalities in the intrauterine formation of the spine and the structures associated with it remains unknown.

Deforming scoliosis of the thoracic region (although scoliosis per se refers to deforming dorsopathies) is defined as structural or rotational curvature of the spinal column with morphological changes that result in the displacement of parts of the skeleton.

Scoliosis is neuromuscular, a rapidly progressing type of spinal curvature, develops with spinal cord injuries and some neurological or muscle diseases (Duchenne muscular dystrophy, cerebral palsy, myelodysplasia).

Degenerative scoliosis, also known as adult scoliosis or de novo scoliosis, develops slowly and is a result of natural aging: deterioration of the vertebral joints and osteoporotic degeneration of the intervertebral discs in the elderly. But most often it occurs in the lumbar spine.

Complications and consequences

What is the danger of thoracic scoliosis? This is a progressive state, that is, the angle of curvature increases, and over time the protrusion of the ribs leads to the formation of a rib hump.

With scoliosis of the thoracic spine of the 3-4 degree, deformation of the chest occurs, resulting in compression and shift of organs located in the mediastinum. This decreases the amount of light that is fraught with dyspnea, obstructive pulmonary disease development [13],  [14]there are problems with the heart (at the left-side thoracic spine deformation). [15], [16]

There is also pinching of the intercostal and spinal nerves with intense pain - a chronic neuropathic pain syndrome.

It is possible to squeeze blood vessels (chest arteries), increase blood pressure, headaches.

The consequences of severe chest scoliosis are restriction of mobility and disability with disability.

Diagnostics of the thoracic scoliosis

The Scoliosis Research Society (USA) recommends annual screening of all children aged 10 to 14 years. The American Academy of Pediatrics recommended screening using a forward bend test during routine visits to a doctor aged 10, 12, 14, and 16.

The classic scoliosis screening test, the forward flexion test, is performed when the patient leans forward at the waist with straight knees and palms together. [17]The doctor should look for any asymmetry in the contours of the back as a result of deformation of the spine during rotation. [18] In classic thoracic scoliosis, the right side of the patient with a curved apex stands out on the right.

All types of scoliotic deformity are diagnosed in the same way, and the basis is instrumental diagnostics: radiography with  spondylometry  and  computed tomography of the spine  [19], [20]

Read also:

• Diagnosis of scoliosis
• Spinal Examination Methods

Differential diagnosis

Differential diagnosis is carried out. In particular, in the absence of obvious external signs of deformation, but in the presence of pain in the spine and between the shoulder blades, scoliosis and thoracic osteochondrosis, intervertebral hernia, arthrosis, or alteration of the facet joints of the thoracic spine, as well as ossification or calcification of its ligaments, should be differentiated.

Treatment of the thoracic scoliosis

Scoliosis takes many different forms, there is no cure for this pathology, and treatment can give temporary results, as the deformation process progresses (in 60% of rapidly growing prepubertal children).

Correction of curvature in childhood can be carried out by longitudinal spinal extension - traction therapy.

To stabilize the spine and reduce the load on its deformed area, tight brace brackets are used, as well as a fixing or corrective orthopedic corset for chest scoliosis (which should be worn 18 hours a day).

One of the methods that may be useful for correcting the position of the vertebrae and increasing the stability of the spine, leads to the relief of back pain shortly after use, has a positive effect on the quality of life, is kinesiotape or taping for scoliosis of the chest (from the English taping - winding) - using an elastic therapeutic tape (kinesio tape). [21], [22]

Patients with breast scoliosis have more hope in physiotherapeutic treatment. It should be borne in mind that massage for chest scoliosis will not correct the curvature of the spine: it is an auxiliary method that helps to relax asymmetrically stressed paravertebral fascia and muscles, reduce chronic back pain, and improve mobility. [23]

Shiatsu is also used - Japanese acupressure for thoracic scoliosis, which gently stimulates blood circulation and nourishes limited areas of muscle tissue around the spine.

The most important role in the long-term reduction of symptoms and the limitation of the functional effect of spinal curvature is played by exercise therapy for thoracic scoliosis. [24]Special exercises for chest scoliosis, which are taught by physical therapy instructors, help to develop coordination and form a new “muscle memory” necessary to stabilize the spine and reduce curvature. [25], [26]

There is a special gymnastics for breast scoliosis: according to the method of Katharina Schrot - for postural correction and correction of the scoliotic type of breathing; functional gymnastics SEAS (Scientific Exercise Approach to Scoliosis - a scientific and practical approach to scoliosis) - according to an individual program adapted to a specific patient (depending on the type and degree of scoliosis). Gymnastics is aimed at correcting curvature and reducing the risk of increasing its arc during the growth period (in children and adolescents), and in adults - at stabilizing the curvature and reducing the level of disability. Exercises are performed two to three times a week for 45 minutes; they train neuromotor function to reflexively stimulate self-correcting posture in everyday life. [27], [28]

Thus, it is known that chiropractic techniques correct the curved spine, restore muscle imbalance, help restore the functions of the spinal nerves, relax the muscles and expand the range of motion. [29],  [30], [31]

Strengthens the muscular corset of the back and muscles on the convex side of the yoga spine in case of chest scoliosis. Hatha yoga asanas such as Vashisthasana, Adho Mukha Shvanasana, variations of Ardha Shalabhasana, Anantasana are recommended.  [32], [33]

Increasing the muscular strength of patients with scoliosis is facilitated by swimming, in which movements are not accompanied by concussion of muscles and vertebral joints. In addition, water during the swimming process has a massaging effect on the muscles of the back, chest and shoulder girdle, improving their blood supply. How to swim with breast scoliosis? Vertebrologists advise avoiding strong overstrain of the muscles of the back and arms and recommend a style such as breaststroke. [34], [35]Although swimming is considered a complete sport and a treatment option for scoliosis, some studies contradict this approach. [36]

More information in the article:  Treatment of scoliosis

When the curvature reaches 45 or 50 °, options for osteotomy are considered - surgical intervention to eliminate / correct deformation and fixation of curved vertebrae. [37]The main surgical treatment is fusion or spinal fusion (selective fusion of the vertebrae). [38]The vertebrae are fixed using special metal structures (which are attached to the spine by hooks or screws above and below the bending area) using a bone auto or allograft, which fuses with the bone tissue of the spine. [39]

As clinical experience and research results show, almost a third of patients who underwent surgery will lose all of its benefits over the next ten years. One in five ultimately needs subsequent operations. [40]Long-term complications of spinal surgery include: postoperative coronary decompensation (4 to 41%), [41], [42]limitation of mobility (20-60%); damage to the spinal nerves (leading to various neurological problems), chronic pain (occurring in 30% of operated patients), permanent disability (in 40% of cases).

More details:

• Surgical treatment of scoliosis .
• Scoliosis: operation

Prevention

Congenital and idiopathic scoliosis of the thoracic spine cannot be prevented. The main prevention is screening: orthopedic examination of the spine in children should be carried out annually, and in 10-12-year-olds - every 6-9 months.

Forecast

Doctors cannot completely correct the skeletal deformity that causes chest scoliosis. Its prognosis depends on the degree of curvature, its causes, the characteristics of the body and especially the musculoskeletal system of patients, as well as the effectiveness of the treatment.