Scoliosis 4 degrees: what to do, treatment, disability

In case of scoliotic deformity of the spine, the degree of curvature is decisive for the choice of treatment tactics and predicting its success, and the most difficult case is grade 4 scoliosis.

This degree means that the lateral deviation of the spine (Cobb angle, measured on an x-ray) is 50 degrees or more.[1]

Epidemiology

The prevalence of scoliosis of various degrees is estimated at 4-8% of the general population. And the prevalence of idiopathic scoliosis, according to foreign sources, ranges from 0.5% to 4.5%. Approximately 30% of patients with idiopathic scoliosis have a family history of the disease.

According to the American Academy of Orthopedic Surgeons, girls over the age of 10 (who have a slightly faster ossification process) have idiopathic scoliosis ten times more common than boys.

And experts from the Scoliosis Research Society note that grade 4 scoliosis is diagnosed in 0.04-0.3% of cases with a ratio of female and male patients of 7:1.

80% of idiopathic scoliosis occurs in adolescents (from 11 to 18 years old), while childhood scoliosis (up to three years old) accounts for 1% of cases, and juvenile (in children 4-10 years old) - 10-15%. 

Scoliosis, which develops in adults (in the absence of its adolescence), has a prevalence of more than 8% in those over 25 years old, and in people 60 years of age or more it rises to 68%, but the statistics of the fourth degree of this type of pathology is unknown.

Causes of the scoliosis 4 degrees

In most patients - in about 8 cases out of 10 - the causes of scoliosis cannot be identified, although, as is known, this disease is often present in the family: in first-line relatives, the incidence is 11%, in the second line - 2.4%.

So the version of genetic predisposition in cases of familial idiopathic scoliosis is being considered, however, specific genes, polymorphism, duplications or mutations of which cause abnormalities in the development of the spine and the process of its deformation, have not yet been accurately identified. Gene linkage studies show that loci on at least a dozen chromosomes may be related to the development of this pathology. For example, the involvement of the GPR126 gene on chromosome 6, which encodes cartilage development and is associated with trunk growth, has been identified. [2]

While grade 4 idiopathic scoliosis (that is, of unknown etiology) is most often diagnosed, possible causes of lateral spinal deformity may be related to:

• with intrauterine anomalies or injuries received during childbirth. For example, thoracolumbar scoliosis of the 4th degree in children may be due to a pathology of phylogenesis - a defect in the embryonic neural tube, leading to incomplete closure of the spinal arch, that is,  spina bifida , or transverse expansion of the vertebrae (plastinospondylia), or such an anomaly of the spinal cord as diastematomyelia;
• with deformation of the facet joints of the spine with spinal gliomatosis (syringomyelia);
• with spinal muscular atrophy or  muscular dystrophy  (such scoliosis is called neuromuscular or myopathic);
• with  neurofibromatosis  (hereditary Recklinghausen disease);
• with spinal dysraphia affecting the musculoskeletal structures and ligaments of the spine;
• with tumors of the spine;
• with a hereditary disorder of methionine metabolism (homocystinuria) and mucopolysaccharidosis;
• with such mesenchymal disorders as Marfan syndrome,  Ehlers-Danlos syndrome , Klippel-Feil, etc., is diagnosed as mesenchymal or syndromic scoliosis;
• in older patients - with degenerative spondylosis (the formation of osteophytes due to the growth of bone tissue of the vertebral joints).

See also -

• Some diseases accompanied by deformation of the spine
• Scoliosis in children
• congenital scoliosis

Scoliosis of the 4th degree of adults with a mature skeleton differs from scoliosis in childhood. In addition to the fact that in adults it can be from adolescence - after surgical treatment or without it (as an advanced case), lateral curvature can develop as a new pathology (scoliosis de novo) - with degenerative changes in the lumbar and lumbosacral spine. [3]

Degenerative lumbar or lumbar scoliosis of the 4th degree in the elderly (aged 65 years and older) may be the result of instability or  displacement of the lumbar vertebrae  (spondylolisthesis), as well as a consequence of surgery (laminectomy) performed with compression of the spinal nerves of various etiologies. However, in most of these cases, the curvature of the spine does not exceed 2 degrees.

Risk factors

Typically, scoliosis begins during periods of growth spurts before or during puberty (10 to 16 years of age) and chest expansion (which begins at 11 to 12 years of age). Therefore, when listing the risk factors for this type of spinal deformity, vertebrologists are the first to name the age factor.

It is followed by belonging to the female sex (girls develop scoliosis much more often than boys), as well as the presence of scoliosis in the family history.

Increased risk of curvature of the spine with persistent violation of posture in childhood and adolescence; injuries of the vertebrae and costovertebral joints; myofascial pain syndrome  (with a compensatory pathological change in posture); congenital deformity of the anterior chest wall (pectus excavatum); the presence in adults of arthrosis of the intervertebral joints (spondylarthrosis) and other  degenerative-dystrophic diseases of the spine ; with hyperestrogenism in adolescent girls and hypoestrogenism in women (especially in postmenopausal women); deficiency of magnesium, vitamins D and K in the body, as well as insufficient body weight.

Pathogenesis

Attempts to explain the potential mechanisms of development - the pathogenesis of scoliosis - led researchers to recognize the polygenicity of this disease with a certain effect on the structures of the musculoskeletal system of genetic factors, neurocirculation disorders, hormonal changes (including sex steroids and melatonin stimulating the division of osteoblasts) and features of general metabolism. [4]

Most of the proposed versions are reduced to the leading pathogenetic role of anomalies of the growth plates (epiphyseal plates) of the vertebral bodies - secondary centers (points) of their ossification, as well as asymmetric growth of the spine. The mechanism of vertebral growth in height is similar to that in long bones: endochondral ossification (ossification) in the growth plates. And the increase in their diameter occurs by appositional growth at the points of ossification adjacent to the intervertebral discs.

How can grade 4 scoliosis develop in children? The longitudinal growth of the vertebral body from the primary points of ossification continues throughout childhood (especially rapidly in the first three years of a child's life), adolescence and adolescence. But during puberty, growth intensifies with the appearance and activation of five secondary ossification centers on the body of each vertebra. [5]

Violation of the ossification process when the growth plates are overloaded on the concave side of the vertebral bodies, their wedge-shaped deformation occurs, which provokes a lateral bending of the spinal segment in the frontal plane and axial twisting of the vertebrae - torsion. This is when the vertebrae are deployed relative to their own axis in the transverse plane: their bodies turn towards the convexity of the scoliotic arc, while the spinous processes extending from the vertebral arc unfold in the direction of the concave part of the arc.

With muscular dystrophy or atrophy of the muscles of the spine, scoliosis or kyphosis, or both curvature at the same time, may develop. As the strength of the supporting vertical position of the spinal column grows, it weakens, and as a result, it curves to the right or left in the upper or middle part with the formation of C-shaped scoliosis, which can progress to grade 4 (with a Cobb angle of 80 ° or more). [6]

Symptoms of the scoliosis 4 degrees

In patients with grade 4 scoliosis, the symptoms are due to the fact that the spine is not only curved, but also twisted. Why the chest loses symmetry and deforms, which leads to a mixture of thoracic organs.

So, scoliosis of the 4th degree of the thoracic region or thoracic scoliosis, in which an arc of curvature is formed by several vertebrae of the thoracic region - in the interval between the third and ninth, is manifested by deformation of the chest, distortion of the suprascapular region, bulging of the scapula, formation of a costal hump (front or back), pain in the back and shortness of breath.

Just below the middle of the thoracic spine, a second curvature in the opposite direction can form, and then a thoracolumbar (thoracolumbar) S-shaped scoliosis of the 4th degree is determined. With it, due to the torsion of the vertebral bodies, the chest and pelvis unfold in different planes - with a skew of the pelvic region (skewness), different lengths of the lower limbs and lameness when walking.

Lumbar or lumbar scoliosis of the 4th degree in 75% of cases is accompanied by spinal pain associated with pelvic distortion and protrusion of the upper edge of the ilium, degenerative changes in the facet joints and displaced intervertebral discs, as well as overload of the paravertebral muscles that resist progressive deformation. 

Scoliosis of the lumbosacral spine of the 4th degree develops in rare cases, since all five vertebrae of the sacral region gradually grow together at the age of 18-25 years, forming a solid bone - the sacrum (sacrum). But if a lateral curvature of this localization occurs, then its symptoms are similar to lumbar scoliosis.

Pregnancy and scoliosis grade 4

Scoliosis of such a high degree, experts attribute to factors that increase the risk of disorders during pregnancy - both for the woman and for the unborn child.

Firstly, as the gestation period increases, the load on the spine increases, especially in the lumbar region (where hyperlordosis is formed), and pain will increase significantly in a pregnant woman with grade 4 lumbar scoliosis. [7]

Secondly, the uterus grows with an increase in the height of its bottom, and with thoracic or thoracolumbar scoliosis of the 4th degree, this will lead to serious problems associated with displacement of the uterus, since the chest is deformed, the internal organs are displaced, and the pelvic part is asymmetric. Therefore, there is  placental insufficiency , and violations of the mechanisms of uteroplacental circulation. In addition, a decrease in lung volume with such a disease of the spine is fraught with insufficient oxygen supply to the fetus, that is, perinatal hypoxia.

Pregnancy with scoliosis of 3 and 4 degrees can be interrupted at any time due to placental abruption (even when it is located normally); in some women with such a diagnosis, the progression of scoliosis of the spine is noted both during childbearing and after birth.

Natural childbirth with scoliosis of the 4th degree of the thoracic spine is possible if the patient underwent surgical treatment of scoliosis several years before. But even in such cases, according to some reports, almost half of the women undergo a caesarean section. [8]

Complications and consequences

What is the danger of scoliosis of the 4th degree? With a given degree of deformation of the spinal column, an uncorrectable change in the center of gravity of the body occurs, which, in turn, leads to an imbalance in the load on the muscles, vertebral joints and ligaments, which causes limitation of mobility and pain of varying intensity.

The normal anatomical position and function of the organs located in the chest are disturbed. In particular, due to a decrease in lung volume in thoracic and thoracolumbar scoliosis, pulmonary hypertension, shortness of breath, and chronic bronchitis develop. It also increases the pressure in the pulmonary circulation, which expands the right heart (the so-called cor pulmonale).

A change in the size of the chest at a Cobb angle of 60 ° leads to a violation of the mechanical functions of the ribs and respiratory muscles (intercostal and diaphragm), a decrease in total lung capacity and clinically pronounced pulmonary dysfunction in the form of shortness of breath during exercise and a decrease in the amount of oxygen entering the body. At an 80° Cobb angle, hypopnea/sleep apnea occurs.

In addition, the consequences and complications of grade 4 scoliosis include: pain in the intestines; development of deforming  spondylarthrosis ; spasms of asymmetrically overloaded muscles; neuropathies, manifested by paresthesia of the limbs.

Scoliosis of 1-3 degrees in children or adolescents - until complete ossification of the vertebrae - is considered to be progressive. Despite the fact that the bone connection of skeletal structures (synestosis) and ossification of the vertebrae is completed by about 25 years, there is a progression of grade 4 scoliosis in adulthood. As clinical practice shows, lumbar scoliosis is less prone to progression than others; most often progresses scoliosis of the 4th degree of the thoracic region. According to studies, the average increase in deviation is 2.4° per year for five years, and in adolescents, scoliosis progresses by an average of 10-12° over 20 years.

Diagnostics of the scoliosis 4 degrees

For details on how diagnostics are carried out, see -  Diagnosis of scoliosis

Instrumental diagnostics, see - radiography of the spine in three projections, CT of the spinal column. [9]

Read also:

• Methods of examination of the spine
• Spondylometry

Treatment of the scoliosis 4 degrees

Attempts at conservative treatment of this degree of scoliosis can be made only in children and the beginning of puberty.

Although numerous clinical studies have shown that the  treatment of grade 4 scoliosis  without surgery - physiotherapy (lateral electrical muscle stimulation), exercise therapy, massage - are ineffective. 

Some experts argue that exercises for scoliosis of the 4th degree are contraindicated due to severe skeletal deformity and serious physical limitations. Others believe that in cases of juvenile curvature of the spine, that is, in children 4-11 years old, three-dimensional exercises and special breathing techniques according to the method of Katarina Schroth can have a therapeutic effect: strengthening and normalizing the tone of the muscles of the trunk, pelvis, lower extremities; improvement in lung and heart function.[10]

Therapeutic massage for scoliosis of the 4th degree is carried out in courses - in order to correct the load on the paravertebral muscles.

For curvature exceeding 40-50°, surgical treatment by spinal fusion is usually recommended - fusion of several vertebrae with bone grafts with mechanical fixation by specially designed metal structures, not static structures are used, but methods of simultaneous correction of the deformity followed by dynamic fixation with a special endocorrector. Adults with degenerative scoliosis and spinal stenosis may require spinal fusion decompression surgery; in case of scoliosis of the lumbar spine, a wedge-shaped osteotomy is used. 

Read more -  Scoliosis: surgery

With idiopathic scoliosis of the 4th degree, it is very rare to make the spine absolutely even, but it is possible to provide a significant correction of both the thoracic and lumbar scoliotic arches: reduce the main frontal curve by approximately 50%, vertebral torsion by 10%, and the vertical position of the spinal column in about 60% on average. [11]

During the period of postoperative rehabilitation, gymnastics is individually selected for scoliosis of the 4th degree, which is aimed at relieving muscle spasms, restoring joint mobility and normal blood circulation.

On the other hand, early and late complications and consequences after surgery for grade 4 scoliosis are not excluded:

• during the operation, there may be significant blood loss, venous air embolism, respiratory distress syndrome, spinal cord injury;
• development of a secondary infection;
• errors of fixation of the vertebrae with the development of a false joint;
• neurological damage with loss of some functions.

Correction of scoliosis with successful fusion in the posterior part of the vertebral bodies in children and adolescents can be complicated by the continued growth of the anterior part of the vertebral body, which exacerbates its curvature and twisting. [12]

Prevention

If you look at grade 4 scoliosis as a neglected case of scoliotic disease, then it immediately becomes clear what its prevention is

These are preventive orthopedic examinations of schoolchildren - to identify the initial stage of any curvature of the spine, explaining (to both children and parents) the principles of correct posture and the consequences of their violation, performing  exercises for posture for children , swimming.

Identified scoliotic deformity must be treated in a timely manner!

Forecast

Scoliosis of this degree can only be controlled, as it is a lifelong diagnosis. And often the prognosis is not encouraging, even with all attempts to stop the progression.

It is difficult for many patients to work, therefore, a medical and social examination in the prescribed manner can give disability in case of scoliosis of the 4th degree (with the subsequent execution of appropriate social benefits).