Congenital deformities of the spine and back pain

One of the most difficult problems in assessing congenital deformities of the spine is the prediction of their course, and consequently - the determination of the timing and indications for surgical intervention. Perhaps the only thing the authors agree on today is that with congenital deformations, conservative methods of treatment are ineffective. At the same time, the attitude towards early surgical treatment of congenital deformities of the spine was recently diametrically opposed: for example, HG Gotze (1978) noted the "senselessness" of prolonged monitoring of prognostically unfavorable congenital deformities, while AI Kazmin (1981) considered early operations with congenital scoliosis "unjustified maximalism." Constantly accumulated experience and a differentiated approach to the evaluation of anomalies allowed us to isolate in each of the anatomical variants of vices the signs with a high degree of probability indicating a favorable or unfavorable course of deformation, and, therefore, as early as possible raise the question of surgical treatment in the presence of indications.

[1], [2], [3]

Congenital scoliosis

Studying the natural course of congenital scoliosis, RB Winter et al. (1968) proposed the following criteria for assessing the rates of progression of congenital deformities of the spine:

• a deformation that does not change in magnitude under dynamic observation, or grows less than 1 ° per year, was regarded by the authors as stable;
• to moderately progressing, scoliosis, increasing by 1 -2 ° per year, is attributed, which leads to a total increase in deformation within 10 years (the "childhood period") by less than 20 °, i.е. Does not exceed the boundaries of one classification degree;
• with rapid progression, the strain increases by 2 ° or more per year. This is more than 20 ° for the "childhood period" and exceeds the boundaries of the classification degree.

In our opinion, it is necessary to speak about the progressive nature of congenital scoliotic deformation in two cases:

1. If the increase in scoliosis is proved by spondylometric methods with dynamic observation of the patient and regular radiographic monitoring. The use of the same methods of estimating deformation in dynamics is, as already noted, fundamental. The rate of deformation progression is calculated by the formula

V => (Sc ₂ -Sc ₁ ) / t,

Where V is the deformation increase in degrees per year, Sc ₂ is the strain value at the end of the observation period, Sc ₁ is the strain value for the primary study, t is the observation duration (in years).

2. If signs are revealed during a clinical examination and an X-ray examination, with a high degree of reliability, evidence of an unfavorable course of deformation.

For many years, the prediction of the course of congenital scoliosis, caused by a violation of the formation of the vertebrae, was based on the definition of the X-ray anatomical version of the semi-vertebra, or rather, the type of its segmentation. In the opinion of IA Movshovich (1964), RB Winter, JH Moe, VE Eilers (1968), each fully segmented vertebra, incl. Anomalous, has two apophysiological growth zones - cranial and caudal. In their opinion, the number of apophyseal growth zones with a fully segmented semi-vertebra on the convex side of the deformation will be two more than on the concave side, which should lead to an asymmetry in the growth of the right and left halves of the spine and an increase in deformation. With a semi-segmented semipore, the number of apophysial growth zones on the convex side of the deformation will be the same as on the concave side, and even less when the segment is not segmented. Thus, fully segmented or "active" semi-vertebrae should be prognostically unfavorable, congenital deformities with them progressing. At the same time, scoliosis with non-segmented semi-vertebrae should be non-progressive. The prognosis for the course of scoliosis with semi-segmented semi-vertebrae, according to the authors, remains uncertain.

The gradual increase in the number of observations of patients with congenital scoliosis made us skeptical about the predictive reliability of the semi-vertebral segmentation pattern. Moreover, the use of MRI in the diagnosis of congenital deformities has cast doubt on the very x-ray concept of segmentation. At present, more predictive value in the evaluation of the dynamics of deformations was obtained by quantitative indicators, calculated by X-ray patterns by mathematical methods.

To predict the course of congenital scoliosis caused by disturbances in the formation of vertebral bodies, use the index of half-vertebral activity, the index of progression of congenital deformity and the coefficient of total dysplasia.

The index of half-vertebral activity (IIa) is calculated from the ratio of the distances between the roots of the contact arches with the anomalous vertebrae, measured on the convex and concave sides of the deformation. The increase in the index in the study of X-ray patterns in the dynamics indicates an increase in the wedge shape of the semi-vertebra and, correspondingly, an increase in the deformation.

The index of deformation progression (Ip) is measured by the ratio of the scoliotic arc to the vertex angle of the wedge shape (the half-vertebrae ("semi-" is in parentheses, since the index can also be calculated with respect to the sphenoid vertebrae.) The progression index reflects not so much the character of the anomaly, how much the degree of compensation of deformation due to the departments contacting the abnormal vertebra.With compensated non-progressive deformation, the value of the index should be less than or equal to 1.0, with progressive (decompensated) - exceed 1.0. During progressive congenital scoliosis, accompanied value Ip> 1.0, frequently observed in cases where a congenital deformation proceeds as idiopathic (dysplastic) scoliosis.

The coefficient of total dysplasia (Ked) takes into account not only the character of the vertex anomaly, but also changes in all vertebrae entering the arc of deformation, which can also be dysplastic.

To assess the progression of congenital scoliosis in vertebral segmentation disorders, by analogy with the index of half-vertebral activity, an index of growth asymmetry was proposed? The growth of which in dynamics also indicates a progression of deformation.

In order to identify the most unfavorable signs of progression of congenital scoliosis, we carried out a polyfactorial analysis that allowed us to identify quantitative and qualitative indices, which with a high degree of probability indicate a possible increase in deformation and, therefore, recommend a more active treatment tactic in these cases even during the initial treatment of the patient. Thus, the presence of the signs shown in the table indicates a prognostically extremely unfavorable course of congenital scoliosis - its rapid progression is noted with a probability greater than 70%.

With violations of the formation of vertebrae, we calculated the probability of rapid progression of congenital scoliosis, depending on the initial magnitude of scoliotic deformity and the severity of the pathological spine rotation.

Signs of high probability of rapid progression of congenital deformities of the spine

When the formation of vertebrae	The presence of a kyphotic deformation component (the probability of progression is close to 90%). One-sided arrangement of 2 or more semi-vertebrae at the top of the arc. The initial value of deformation is more than 30 °. The presence of severe pathological rotation (2 or more degrees according to the pedicle method). The presence of versatile semi-vertebrae, separated from each other by more than 3 segments. The value of the activity index of the half-bend is> 2.3. The magnitude of the deformation progression index is> 1.1.
When vertebral segmentation is impaired	Any kyphogenic variant of vice. Violation of segmentation by the type of "blocking through the segment." The initial value of deformation is more than 30 °. The thoracolumbar locus of the defect. The value of the asymmetry index is> 1.3.
With mixed defects	Prognostically unfavorable combination of any mutually burdening variants of defects.

The probability of rapid progression of scoliotic deformation, depending on its initial value

Initial value of scoliosis	The probability of rapid progression
Less than 30 °	16%
30-50 °	70%
More than 50 °	100%

The probability of rapid progression of deformation, depending on the degree of pathological rotation (torsion)

Degree of torsion according to pedicle-method	The probability of rapid progression
0-1 st II-IV ct	15% 80%

[4], [5], [6], [7]