Diagnosis of scoliosis

Diagnosis of scoliosis begins with the collection of anamnesis. It is necessary to find out at what age and by whom the scoliosis was first diagnosed, whether the parents of the patient consulted the doctor, which treatment of scoliosis was carried out and what its effect was. It is extremely important to get acquainted with the patient's medical records, especially when there are indications of previous surgical treatment of scoliosis. It is necessary to find out what was the dynamics of the progression of deformation, with what age the peaks of this progression coincided. One should inquire about the state of the functions of the pelvic organs. Finally, since the overwhelming majority of patients with spinal deformities are girls, it is necessary to clarify at what age menstruation started (if this already happened) and whether a normal menstrual cycle was established.

The next step is to find out the patient's complaints. The main complaints are usually two: a cosmetic defect associated with deformation of the spine and thorax. And back pain. It should be borne in mind that assessing patients their appearance is excessively variable. A relatively small scoliosis (40-45 Cobb) can bring a young patient severe moral suffering. At the same time, patients with scoliosis from 75-80 often believe that their appearance is quite acceptable and does not need correction. Approximately the same can be the case with pain syndrome. Often a teenager does not focus his attention on him and only with a purposeful questioning clarifies that the back hurts. It is necessary to find out if the patient is worried about shortness of breath, when it appeared, under what stresses and whether it increases with age.

An orthopedic examination of the patient is one of the most important elements of the survey. It must be carefully and properly documented. An integral and most important part of the clinical examination is the examination of the patient by a neuropathologist. The orthopedist and neuropathologist are required to work in constant contact, especially if the patient's condition provokes ambiguous interpretation.

[1], [2], [3], [4], [5], [6], [7]

Radiographic diagnosis of scoliosis

Radiography includes spondylography of the thoracic and lumbar spine (from Th1 to SI) in two standard projections in the patient's standing position. Spondylograms performed in the lying position are not informative.

Functional radiography

When planning surgical intervention, information is needed concerning the mobility of individual vertebral segments. Radiography with lateral inclinations of the trunk of the patient is performed in the position on the back. Slopes the patient performs actively, in the direction of convexity of the main and compensatory arcs separately.

The second version of the study of mobility of the spine in scoliosis - traction spondylograms (in a standing or lying position). Spondylograms of the lumbar spine in the position of flexion and extension are performed to clarify the condition of the lumbar intervertebral discs when planning the length of the scoliosis zone of the scoliosis.

X-ray analysis

Radiographic examination provides an opportunity to assess the deformation of the spine in many ways.

First of all, we are talking about etiology. The presence of congenital vertebrae anomalies (wedge vertebrae and semi-vertebrae, segmentation disorders) and ribs (synostosis, underdevelopment) indicates the inherent nature of deformation. A short rough arc makes one think of neurofibromatosis, and a long, gentle arc about the neuromuscular etiology of scoliosis. In turn, the absence of these and other changes indicates that scoliosis is most likely idiopathic. Next, the type of scoliotic deformation is determined by the localization of its apex, the side of the convexity, the boundaries, and performs measurements that characterize the deformation from a quantitative point of view.

Scoliosis - a three-dimensional deformation of the spine, so the study is carried out in three planes.

Frontal plane

Determination of the magnitude of the scoliotic component of deformation all over the world is performed in accordance with the Cobb method described in 1948.

The first stage is the localization of the apical and terminal vertebrae of the scoliotic arch. Vertex, or apical, vertebra is located horizontally. The last vertebra from the number of inclined is called the end. The lower end vertebra of the marginal arch can also be the upper terminal vertebra of caudal anticoagulation.

The second stage is the conduct on the spondylogram of straight lines, at the intersection of which the desired angle is formed. The first line runs strictly along the cranial closure plate of the upper terminal vertebra, the second line follows the caudal closure plate of the lower terminal vertebra. In cases where the end plates are poorly visualized, it is permissible to hold these lines through the upper or lower edges of the shadows of the roots of the arcs. Crossing them within the standard film is possible only with coarse scoliosis. In other cases, the lines intersect outside the film, then to be able to measure the angle of the scoliotic arc, it is necessary to restore the perpendiculars to both lines.

The third stage is the measurement of the obtained angle and the recording of the result on the radiograph and in the medical history.

Sagittal plane

The size of the thoracic kyphosis and lumbar lordosis is also determined in accordance with the Cobb method. If the profile spondylogram of the patient is examined with scoliosis, it is necessary to measure the curvature of the entire thoracic spine - from Th1 to Th2. It is perfectly permissible to measure from Th4 to Th12. It is important that all the measurements of this particular patient are made at the same levels. Through the cranial closure plate of the upper terminal vertebra and the caudal closure plate of the lower terminal vertebra, straight lines are drawn, at the intersection of which an angle characterizing the magnitude of the deformation is formed. The lumbar lordosis is measured from L1 to S1.

Horizontal plane

Deformation of the spinal column in the horizontal plane, i.e. Rotation of the vertebrae around the vertical axis, is the main component of the mechanogenesis of idiopathic scoliosis. It is maximally expressed at the level of the apical vertebra and progressively decreases in the direction of both terminal vertebrae of the arch. The most striking radiographic manifestation of rotation is the change in the location of the shadows of the roots of the vertex vertebra arches on a direct spondylogram. Normally, in the absence of rotation, these shadows are located symmetrically with respect to the midline of the vertebral body and its marginal structures. In accordance with the proposal, Nash and Moe determine the degree of rotation - from 0 to IV.

The zero degree of rotation practically corresponds to the norm, when the shadows of the roots of the arms are symmetrical and located at the same distance from the side closure plates of the vertebral body.

At the I degree of rotation, the root of the arch on the convex side of the scoliotic arc is displaced towards the concavity and occupies a position asymmetric relative to the corresponding closure plate and the root of the opposite arch.

At the third degree, the root of the bow, corresponding to the convex side of the deformation. Is located in the projection of the middle of the shadow of the vertebral body, and in the second degree rotation it occupies an intermediate position between the I and III degrees. The extreme degree of rotation (IV) is characterized by the mixing of the shade of the root of the arch of the convex side of the arc over the middle line of the vertebral body - closer to the medial lateral closure plate. A more precise definition of the degree of rotation is given by the Perririolle technique, which assumes the use of a special ruler - a torsiometer. Beforehand, the largest vertical diameter of the shadow of the root of the arch corresponding to the convex side of the deformation (point B) should be determined. Next, mark the points A and A ¹, located at the height of the "waist" - the body of the vertebra medially and laterally, the torsiometer is superimposed on the sondhilogram so that the points A and A ¹ are located on the edges of the ruler. It remains to determine which of the lines of the scale of the torsiometer is the maximum vertical diameter of the shadow of the root of the arc of the point B.

When anomalies in the development of vertebrae and ribs are detected, their identification and localization are necessary. All vertebrae, both complete and supernumerary, should be numbered in the craniocaudal direction, determine the nature of the anomaly and clarify the correspondence of the ribs to the vertebrae and the half-vertebrae, and the synostosis of the ribs - which of them are blocked: The vertebral numbering is mandatory not only in the presence of congenital anomalies, but also absolutely in all cases, and in the craniocaudal direction. Neglect of this rule will inevitably lead to mistakes in the planning and implementation of surgical intervention. Documenting the radiographic survey data should be as pedantic and methodologically consistent as the results of the clinical examination.

Special methods of radiographic examination

Tomography (laminography), a layered study of a limited area of the spinal column, makes it possible to clarify the features of the anatomical structure of bone structures that are not sufficiently visualized in conventional spondylograms. Magnetic resonance imaging (MRI) is a method that allows studying not only bone, but also soft tissue structures, which, with respect to the spine, makes it possible to evaluate the state of the intervertebral discs and the contents of the spinal canal. A large scoliotic component of deformation complicates the picture, in these cases a combination of MRI with myelography is useful.

Computer tomography (CT) helps in difficult cases, if necessary, to localize the cause of radiculopathy in scoliosis or compression of the spinal cord. Such visualization is facilitated by the performance of CT after myelography, since in the presence of contrast it is easier to determine the location and nature of the compression of the contents of the spinal canal. CT without contrast shows only the narrowing of the spinal canal.

In the study of the urinary system, it is necessary to take into account the frequent combination of spinal deformities, especially congenital ones, with the pathology of the element of this system. Kidney ultrasound and intravenous pyelography provide enough information that can influence the orthopedist's decision when planning an operative intervention.

Laboratory diagnosis of scoliosis

Laboratory tests include general blood and mota tests, biochemical indicators of liver function, and a study of the coagulation system. Mandatory blood group and Rh-accessory are determined. Conduct a von Wasserman reaction and analyzes for the detection of AIDS. The function of external respiration is also routinely examined. It is highly desirable to determine the immune status, so that if necessary, a correction is made in the preoperative period. In the presence of a biomechanical laboratory, it becomes possible to evaluate the characteristics of a patient's gait in pre- and postoperative periods. This allows to further objectify the result of the correction of the spinal deformity in terms of normalizing locomotion functions and restoring the balance of the trunk. Obligatory diagnosis of scoliosis for the vertebrological clinic is photographing the patient from three points before and after the operation, as well as at the observation stages.