Scoliosis
Scoliosis (from Greek: skoliōsis meaning from skolios, "crooked")
is a medical condition in which a person's spine is curved from
side to side. Although it is a complex three-dimensional deformity,
on an X-ray, viewed from the rear, the spine of an individual with
scoliosis may look more like an "S" or a "C" than a straight line.
Scoliosis is typically classified as either congenital (caused by
vertebral anomalies present at birth), idiopathic (cause unknown,
subclassified as infantile, juvenile, adolescent, or adult, according
to when onset occurred), or neuromuscular (having developed as a
secondary symptom of another condition, such as spina bifida,
cerebral palsy, spinal muscular atrophy, or physical trauma).
Contents
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1 Signs and symptoms
1.1 Associated conditions
2 Cause
3 Diagnosis
3.1 Genetic testing
4 Management
4.1 Physiotherapy
4.2 Occupational Therapy
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4.2.1 Self-care
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4.2.2 Productivity
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4.2.3 Leisure
4.3 Bracing
4.4 Surgery
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4.4.1 Spinal fusion with instrumentation
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4.4.2 Thoracoplasty
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4.4.3 Complications
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4.4.4 Surgery without fusion
5 Prognosis
6 Epidemiology
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7 Society and culture
7.1 Scoliosis Research Society
7.2 About Skolyoz Destek Grubu
8 See also
9 References
Signs and symptoms
Patients having reached skeletal maturity are less likely to have a
worsening case. Some severe cases of scoliosis can lead to
diminishing lung capacity, putting pressure on the heart, and
restricting physical activities.
The signs of scoliosis can include:
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Uneven musculature on one side of the spine
A rib prominence and/or a prominent shoulder blade, caused
by rotation of the ribcage in thoracic scoliosis
Uneven hips/leg lengths
Slow nerve action (in some cases)
Associated conditions
Scoliosis is sometimes associated with other conditions such as
Ehlers–Danlos syndrome (hyperflexibility, "floppy baby"
syndrome, and other variants of the condition), Charcot–Marie–
Tooth disease, Prader–Willi syndrome, kyphosis, cerebral palsy,
spinal muscular atrophy, muscular dystrophy, familial
dysautonomia, CHARGE syndrome, Friedreich's ataxia, Fragile X
syndrome[2][3], proteus syndrome, spina bifida, Marfan's syndrome,
neurofibromatosis, connective tissue disorders, congenital
diaphragmatic hernia, hemihypertrophy, and craniospinal axis
disorders (e.g., syringomyelia, mitral valve prolapse, Arnold–
Chiari malformation), and Amniotic Band Syndrome (ABS).
Scoliosis associated with known syndromes such as Marfan's or
Prader–Willi is often sub-classified as "syndromic scoliosis."
Cause
It has been estimated that approximately 65% of scoliosis cases are
idiopathic, approximately 15% are congenital and approximately
10% are secondary to a neuromuscular disease.[4]
Idiopathic scoliosis is a condition which lasts a lifetime, but it does
not increase the risk of mortality.
In adolescent idiopathic scoliosis, there is no clear causal agent and
it is generally believed to be multifactorial, although genetics are
believed to play a role.[6] Various causes have been implicated, but
none of them have consensus among scientists as the cause of
scoliosis, though the role of genetic factors in the development of
this condition is widely accepted. Still, at least one gene, notably
CHD7, has been associated with the idiopathic form of scoliosis.
In some cases, scoliosis exists at birth due to a congenital vertebral
anomaly.
Scoliosis secondary to neuromuscular disease may develop during
adolescence, such as with tethered spinal cord syndrome. Scoliosis
often presents itself, or worsens, during the adolescence growth
spurt and is more often diagnosed in females versus males.
Diagnosis
Patients who initially present with scoliosis are examined to
determine whether there is an underlying cause of the deformity.
During a physical examination, the following is assessed:
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Skin for café au lait spots, indicative of neurofibromatosis
The feet for cavovarus deformity
Abdominal reflexes
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Muscle tone for spasticity
During the exam, the patient is asked to remove his or her shirt and
bend forward. This is known as the Adams Forward Bend Test
and is often performed on school students. If a prominence is
noted, then scoliosis is a possibility and the patient should be sent
for an X-ray to confirm the diagnosis.
As an alternative, a scoliometer may be used to diagnose the
condition.[11] The patient's gait is assessed, and there is an exam for
signs of other abnormalities (e.g., spina bifida as evidenced by a
dimple, hairy patch, lipoma, or hemangioma). A thorough
neurological examination is also performed.
It is usual, when scoliosis is suspected, to arrange for weightbearing full-spine AP/coronal (front-back view) and lateral/sagittal
(side view) X-rays to be taken. This is to assess the scoliosis
curves and the kyphosis and lordosis, as these can also be affected
in individuals with scoliosis. Full-length standing spine X-rays are
the standard method for evaluating the severity and progression of
the scoliosis, and whether it is congenital or idiopathic in nature. In
growing individuals, serial radiographs are obtained at 3–12 month
intervals to follow curve progression, and, in some instances, MRI
investigation is warranted to look at the spinal cord.
The standard method for assessing the curvature quantitatively is
measurement of the Cobb angle, which is the angle between two
lines, drawn perpendicular to the upper endplate of the uppermost
vertebrae involved and the lower endplate of the lowest vertebrae
involved. For patients with two curves, Cobb angles are followed
for both curves. In some patients, lateral-bending X-rays are
obtained to assess the flexibility of the curves or the primary and
compensatory curves.
Genetic testing
Genetic testing for AIS, which became available in 2009 and is
still under investigation, attempts to gauge the likelihood of curve
progression.
Through a genome-wide association study, geneticists have
identified single nucleotide polymorphism markers in the DNA
that are significantly associated with adolescent idiopathic
scoliosis. Fifty-three genetic markers have been identified.
Scoliosis has been described as a biomechanical deformity, the
progression of which is dependent on asymmetric forces otherwise
known as the Heuter-Volkmann law.[12][13]
Management
The traditional medical management of scoliosis is complex and is
determined by the severity of the curvature and skeletal maturity,
which together help predict the likelihood of progression.
The conventional options are, in order:
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2.
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4.
5.
6.
7.
Observation
Physical Therapy
Occupational Therapy
Chiropractic or Osteopathic Therapy
Casting (EDF)
Bracing
Surgery
A growing body of scientific research testifies to the efficacy of
specialized treatment programs of physical therapy, which may
include bracing.[14] Debate in the scientific community about
whether chiropractic and physical therapy can influence scoliotic
curvature is partly complicated by the variety of methods proposed
and employed: Some are supported by more research than others.
Physiotherapy
The Schroth method is a noninvasive, physiotherapeutic treatment,
which has been used successfully in Europe since the 1920s.
Originally developed in Germany by scoliosis sufferer Katharina
Schroth, this method is now taught to scoliosis patients in clinics
specifically devoted to Schroth therapy in Germany, Spain,
England, and North America. The method is based upon the
concept of scoliosis as resulting from a complex of muscular
asymmetries (especially strength imbalances in the back) that can
be at least partially corrected by targeted exercises.[17]
The Schroth method has proven effective at reversing abnormal
scoliotic curvatures by an average of 10% in 4- to 6-week inpatient programs,[18] and by 30% or more in an out-patient program
over a period of a year.[19] One study of nearly 200 adolescent
Schroth patients found no curve progression three years following
the in-patient program.[20] Several studies have documented the
Schroth method's efficacy in substantially reducing or eliminating
pain, which tends to be a problem, in particular, for adults.[21]
Small curvatures between 15 and 20° during growth may be
treated with the physio-logic-program,[22] curvatures between 20
and 30° during growth spurt with "3D-made-easy". This program
has been tested in the environment of in-patient treatment as
well.[23][24] In curvatures exceeding 30°, a combination of the
methods described together with the Schroth program may be
helpful,[25] and a specialized centre with trained and certified staff
should be taken into account. Out-patient rehabilitation treatments
today may reach the same outcome as in-patient programs.[26] Outpatient programs may be successful when pattern-specific
programs are provided. A certain intensity is necessary to allow the
very best compliance with conservative treatment, and to acquire
strategies for coping with scoliosis and with the conservative
treatment.
The indications for treatment depend on degree of curvature,
maturity of the patient, and the individual curve pattern. While
evidence supporting such conservative, non-invasive treatments is
weak, today conservative management of scoliosis can be regarded
as being evidence-based; no substantial evidence has been found to
support surgical intervention.
Kyphosis
Kyphosis (Greek - kyphos, a hump), also called roundback or
Kelso's hunchback, is a condition of over-curvature of the thoracic
vertebrae (upper back). It can be either the result of degenerative
diseases (such as arthritis), developmental problems (the most
common example being Scheuermann's disease), osteoporosis with
compression fractures of the vertebrae, and/or trauma.
In the sense of a deformity, it is the pathological curving of the
spine, where parts of the spinal column lose some or all of their
lordotic profile. This causes a bowing of the back, seen as a
slouching posture.
While most cases of kyphosis are mild and only require routine
monitoring, serious cases can be debilitating. High degrees of
kyphosis can cause severe pain and discomfort, breathing and
digestion difficulties, cardiovascular irregularities, neurological
compromise, and in the more severe cases, significantly shortened
life-spans. These types of high end curves typically do not respond
well to conservative treatment, and almost always warrant spinal
fusion surgery, which can successfully restore the body's natural
degree of curvature.
The Cobb angle is the preferred method of measuring kyphosis.
Contents
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1 Classification
2 Treatments
2.1 Orthosis (brace)
2.2 Specialised physical therapy
2.3 Surgery
2.4 Complications
3 See also
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4 References
5 External links
Classification
There are several kinds of kyphosis (ICD-10 codes are provided):
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Postural kyphosis (M40.0), the most common type,
normally attributed to slouching, can occur in both the old[1] and
the young. In the young, it can be called 'slouching' and is
reversible by correcting muscular imbalances. In the old, it may
be called 'hyperkyphosis' or 'dowager’s hump'. About one third
of the most severe hyperkyphosis cases have vertebral
fractures.Otherwise, the aging body tends towards a loss of
musculoskeletal integrity, and kyphosis can develop due to
aging alone.
Scheuermann's kyphosis (M42.0) is significantly worse
cosmetically and can cause varying degrees of pain, and can
also affect different areas of the spine (the most common being
the mid-thoracic area). Scheuermann's disease is considered a
form of juvenile osteochondrosis of the spine, and is more
commonly called Scheuermann's disease. It is found mostly in
teenagers and presents a significantly worse deformity than
postural kyphosis. A patient suffering from Scheuermann’s
kyphosis cannot consciously correct posture. The apex of the
curve, located in the thoracic vertebrae, is quite rigid. The
patient may feel pain at this apex, which can be aggravated by
physical activity and by long periods of standing or sitting. This
can have a significantly detrimental effect on their lives, as their
level of activity is curbed by their condition; they may feel
isolated or uneasy amongst peers if they are children, depending
on the level of deformity. Whereas in postural kyphosis, the
vertebrae and disks appear normal, in Scheuermann’s kyphosis,
they are irregular, often herniated, and wedge-shaped over at
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least three adjacent levels. Fatigue is a very common symptom,
most likely because of the intense muscle work that has to be
put into standing and/or sitting properly. The condition appears
to run in families. Most patients who undergo surgery to correct
their kyphosis have Scheuermann's disease.
Congenital kyphosis (Q76.4) can result in infants whose
spinal column has not developed correctly in the womb.
Vertebrae may be malformed or fused together and can cause
further progressive kyphosis as the child develops. Surgical
treatment may be necessary at a very early stage and can help
maintain a normal curve in coordination with consistent follow
ups to monitor changes. However, the decision to carry out the
procedure can be very difficult due to the potential risks to the
child. A congenital kyphosis can also suddenly appear in
teenage years, more commonly in children with cerebral palsy
and other neurological disorders.
Nutritional kyphosis can result from nutritional deficiencies,
especially during childhood, such as vitamin D deficiency
(producing rickets), which softens bones and results in curving
of the spine and limbs under the child's body weight.
Gibbus deformity is a form of structural kyphosis, often a
sequela to tuberculosis.
Post-traumatic kyphosis (M84.0) after untreated or not
treated effectively vertebral fractures
Treatments
Orthosis (brace)
Modern brace for the treatment of a thoracic kyphosis. The brace is
constructed using a CAD / CAM device. At this stage, this is the
only CAD / CAM brace designed to treat a thoracic kyphosis. It is
called kyphologic.
Body braces showed benefit in a randomised controlled trial.
The Milwaukee brace is one particular body brace that is often
used to treat kyphosis in the US. Modern CAD / CAM braces are
used in Europe to treat different types of kyphosis. These are much
easier to wear and have better in-brace corrections than reported
for the Milwaukee brace. Since there are different curve patterns
(thoracic, thoracolumbar and lumbar) different types of braces are
in use. The advantages / disadvantages of different braces are
discussed in a recent review article.[7]
Modern brace for the treatment of a lumbar / thoracolumbar
kyphosis. The brace is constructed using a CAD / CAM device. At
this stage this brace is the only CAD / CAM brace designed to treat
a lumbar kyphosis and is called physio-logic brace. Restoration of
the lumbar lordosis is the major aim.
Specialised physical therapy
In Germany, a standard treatment for both Scheuermann's disease
and lumbar kyphosis is the Schroth method, a system of physical
therapy for scoliosis and related spinal deformities.
Surgery
Surgical treatment can be used in severe cases. In patients with
progressive kyphotic deformity due to vertebral collapse, a
procedure called a kyphoplasty may arrest the deformity and
relieve the pain. Kyphoplasty is a minimally invasive procedure,
requiring only a small opening in the skin. The main goal is to
return the damaged vertebra as close as possible to its original
height.
Complications
The risk of serious complications from spinal fusion surgery for
kyphosis is estimated to be 5%, similar to the risks of surgery for
scoliosis. Possible complications may be inflammation of the soft
tissue or deep inflammatory processes, breathing impairments,
bleeding, and nerve injuries. According to the latest evidence, the
actual rate of complications may be substantially higher. Even
among those who do not suffer serious complications, 5% of
patients require reoperation within five years of the procedure, and
in general it is not yet clear what to expect from spine surgery in
the long-term. Taking into account that signs and symptoms of
spinal deformity cannot be changed by surgical intervention,
surgery remains to be a cosmetic indication. Unfortunately, the
cosmetic effects of surgery are not necessarily stable. In case one
decides to undergo surgery, a specialised centre should be
preferred.
1.
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Lordosis
Lordosis is a medical term used to describe an inward curvature of
a portion of the lumbar and cervical vertebral column. Two
segments of the vertebral column, namely cervical and lumbar, are
normally lordotic, that is, they are set in a curve that has its
convexity anteriorly (the front) and concavity posteriorly (behind),
in the context of human anatomy. When referring to the anatomy
of other mammals, the direction of the curve is termed ventral.
Curvature in the opposite direction, that is, apex posteriorly
(humans) or dorsally (mammals) is termed kyphosis. Excessive or
hyperlordosis is commonly referred to as swayback or saddle
back, a term that originates from the similar condition that arises
in some horses.
A major factor of lordosis is anterior pelvic tilt, when the pelvis
tips forward when resting on top of the femurs.
Cause
A consequence of the normal lordotic curvatures of the vertebral
column, (also known as secondary curvatures) is that there are
differences in thickness between the anterior and posterior part of
the intervertebral disc. Lordosis may also increase at puberty
sometimes not becoming evident until the early or mid-20s.
Imbalances in muscle strength and length are also a cause, such as
weak hamstrings, or tight hip flexors (psoas).
Excessive lordotic curvature is also called hyperlordosis, hollow
back, saddle back, and swayback. Common causes of excessive
lordosis include tight low back muscles, excessive visceral fat, and
pregnancy. Although lordosis gives an impression of a stronger
back, incongruently it can lead to moderate to severe lower back
pain. Rickets, a vitamin D deficiency in children, can cause lumbar
lordosis.
Treatment
Lordosis of the lower back may be treated by strengthening the hip
extensors on the back of the thighs, and by stretching the hip
flexors on the front of the thighs. Too much importance has been
attributed to the abdominal muscles in maintaining a neutral spine
position. They may help by pushing the internal organs against the
spine hence alleviating the lumbar curvature but they can't rotate
the pelvis backward while in a standing position. Also the lumbar
erector spinae is not able to rotate the pelvis forward while
standing, hence its strengthening is not to be avoided during
lordosis treatment. Only the muscles on the front and on the back
of the thighs can rotate the pelvis forward or backward while in a
standing position because they can discharge the force on the
ground through the legs and feet. Abdominal muscles and erector
spinae can't discharge force on an anchor point while standing,
unless one is holding his hands somewhere, hence their function
will be to flex or extend the torso, not the hip. Back hyperextensions on a Roman chair or inflatable ball will strengthen all
the posterior chain and will treat lordosis. So too will stiff legged
deadlifts and supine hip lifts and any other similar movement
strengthening the posterior chain without involving the hip flexors
in the front of the thighs. Abdominal exercises could be avoided
altogether if they stimulate too much the psoas and the other hip
flexors. Strengthening of the hip extensors, which are on the back
of the thighs, and optionally stretching of the hip flexors, which are
on the front of the thighs, will be enough to treat a lordosis in quite
a short time. Anti-inflammatory pain relievers may be taken as
directed for short-term relief.
Physical therapy effectively treats 70% of back pain cases due to
scoliosis, kyphosis, lordosis, and bad posture. Measurement and
diagnosis of lumbar lordosis can be difficult. Obliteration of
vertebral end-plate landmarks by interbody fusion may make the
traditional measurement of segmental lumbar lordosis more
difficult. Because the L4-L5 and L5-S1 levels are most commonly
involved in fusion procedures, or arthrodesis, and contribute to
normal lumbar lordosis, it is helpful to identify a reproducible and
accurate means of measuring segmental lordosis at these levels.[2][3]
Hypo-lordosis is more common than Hyper-lordosis. Hypolordosis can be corrected non-surgically through rehabilitation
exercises. Many different techniques exist to accomplish this
correction. These exercises, if done correctly, may reduce
symptoms in those with the typical presentation in 3-6 months. The
type of practitioner that usually offers this type of treatment is
usually a Chiropractor, some physical therapists do this type of
rehab but it is not very common.[4][5]
In non-human animals
Lordosis is seen in non-humans, in particular horses and other
equines. Usually called "swayback," soft back, or low back, it is an
undesirable conformation trait. Swayback is caused in part from a
loss of muscle tone in both the back and abdominal muscles, plus a
weakening and stretching of the ligaments. As in humans, it may
be influenced by bearing young; it is sometimes seen in a
broodmare that has had multiple foals. However, it is also common
in older horses whose age leads to loss of muscle tone and
stretched ligaments. It also occurs due to overuse or injury to the
muscles and ligaments from excess work or loads, or from
premature work placed upon an immature animal. Equines with too
long a back are more prone to the condition than those with a short
back, but as a longer back is also linked to smoother gaits, the trait
is sometimes encouraged by selective breeding. It has been found
to have a hereditary basis in the American Saddlebred breed,
transmitted via a recessive mode of inheritance. Research into the
genetics underlying the condition has several values beyond just
the Saddlebred breed as it may "serve as a model for investigating
congenital skeletal deformities in horses and other species."[6]
Other
Lordosis behavior refers to the position that some mammalian
females (including cats, mice, and rats) display when they are
ready to mate ("in heat"). The term is also used to describe
mounting behavior in mammalian males.
In radiology, a lordotic view is an X-ray taken of a patient leaning
backwards