Scoliosis in children

One of the most common orthopedic diseases - scoliosis in children, or lateral curvature of the spine, combined with its torsion (according to ICD-10 code M41). The frequency of scoliotic deformities of the spine, according to various authors, varies from 3 to 7%, with 90% accounted for the share of idiopathic scoliosis. Scoliosis in children is found in all races and nationalities, more often they suffer from female faces - up to 90%.

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

Epidemiology of scoliosis in children

The prevalence of any pathological condition can be established only by screening surveys of large masses of the population. Determine the number of individuals in a population having scoliotic deformation at any one time interval. Two types of examinations were conducted: based on chest radiography for screening for tuberculosis and school screening. The number of examined patients ranged from 10,000 to 2,500,000 people, with the frequency of revealed spinal deformities (in the vast majority of cases it was idiopathic scoliosis in children) ranged from 1.0 to 1.7%. In all studies only deformations exceeding 10 ° Cobb were taken into account.

Is the prevalence of scoliosis all over the world? Are there any racial, national or geographical differences? In Japan, 2000 schoolchildren in Chiba were examined and found structural deformities in 1.37% of cases, while Takemitzu, after examining 6949 schoolchildren in Hokkaido, found scoliosis in children in 1.9% of cases. Skogland and Miller, who conducted research in Northern Norway, found scoliosis in children in Laplandians in 0.5% of cases, and in the rest of the population in 1.3%.

Dommisse in South Africa found scoliosis in children in 1.7% of cases in a survey of 50,000 white children in Pretoria (90% of scoliosis - idiopathic). Segil in Jogansburg examined students of the European and Negroid race (Bantu) and found deformations of 10 ° or more in Caucasians in 2.5% of cases, and in Negroids - only in 0.03%. Span et al. Surveyed 10,000 schoolchildren 10-16 years in Jerusalem. In Jewish schoolchildren, deformation was detected 2 times more often than in Arabian.

For the etiological factor, scoliosis is classified as follows.

• Idiopathic scoliosis in children, i.e. Scoliosis of unknown cause.
• Congenital scoliosis in children - on the basis of congenital malformations of the vertebrae.
• Scoliosis in children with systemic congenital diseases of the musculoskeletal system (Marfan syndrome, Ehlers-Danlos and others).
• Paralytic scoliosis in children, due to advanced poliomyelitis or after trauma to the spine and spinal cord.
• Neurogenic scoliosis in children, the cause of which is degenerative-dystrophic diseases of the spine or other neurological diseases.
• Scarring scoliosis in children is the result of severe burns or extensive surgical interventions on the chest.

Classification of types of scoliosis by localization of the main arc (vertex) of curvature.

• Upper thoracic (apex of curvature: III-IV thoracic vertebra).
• Thoracic (top of curvature: VIII-IX thoracic vertebra).
• Lumbosacral (apex of curvature: XI-XII thoracic vertebra or I lumbar).
• Lumbar (vertex of curvature II-III lumbar vertebra).
• Combined (or S-shaped) with the same amount of curvature and torsion in both arcs located in different parts of the spine, the difference in magnitude is not more than 10 °.

In the direction of the convexity of the curvature arc, the left, right, and combined scoliosis in children is distinguished (it combines two basic multidirectional curves of curvature).

To determine the severity of scoliosis, the classification of VD is used. Chaklin (1963), based on the measurement of the angle of the main arc of curvature on the x-ray of the spine performed in a direct projection in the standing patient position: I degree - 1-10 °, grade II - 11-30 °, III degree - 31-60 °, IV degree - more than 60 °.

An example of the formulation of the diagnosis: "idiopathic right-sided thoracic scoliosis in children of the third degree".

[7], [8], [9], [10], [11], [12], [13], [14]

Pathogenesis of scoliosis

The main pathogenetic links in the development of idiopathic scoliosis are pathological rotation of the vertebrae in the horizontal plane, displacement toward the pulpous core, frontal spine and torsion of the vertebrae.

Etiological classification of scoliosis

I. Idiopathic scoliosis in children

• Infantile scoliosis in children (from birth to 3 years).
  • Self-resolving.
  • Progressing.
• Juvenile scoliosis in children (from 3 to 10 years).
• Adolescent scoliosis in children (over 10 years).

II. Neuromuscular scoliosis

A. Neuropathic scoliosis in children.

• 1. Scoliosis in children on the basis of defeat of the upper motoneuron:
  • cerebral paralysis:
  • vertebral-cerebellar degeneration;
    • Friedreich's disease;
    • Charcot-Marie-Tooth disease;
    • Roussy-Levy disease;
  • syringomyelia;
  • swelling of the spinal cord;
  • spinal cord injury;
  • other reasons.
• On the basis of the defeat of the lower motoneuron:
  • polio;
  • other viral myelitis;
  • injury;
  • vertebral-muscular atrophy:
    • Werdnig-Hoffmann disease;
    • Kugelberg-Welander disease;
    • myelomeningocele (paralytic).
• Dysautonomy (Riley Day Syndrome).

B. Myopathic scoliosis in children

• Arthrogryposis
• Muscular dystrophy,
• Congenital hypotension,
• Dystrophically myotonia.

III. Congenital scoliosis in children

A. Violation of formation.

• The sphenoid vertebra.
• Semi-vertebra.

B. Violation of segmentation.

• Unilateral scoliosis in children.
• Two-sided scoliosis in children.

B. Mixed anomalies.

IV. Neurofibromatosis.

V. Mesenchymal pathology.

• Marfan's syndrome.
• Ehlers-Danlos Syndrome.

VI. Rheumatoid diseases.

• Juvenile rheumatoid arthritis.

VII. Traumatic deformations.

• After the fracture.
• After surgery:
  1. Post-amniectomy.
  2. Posttoraplastic.

VIII. Scoliosis in children on the basis of contractures of extrinsic localization.

• After the empyema.
• After burns.

IX. Osteochondrodystrophy scoliosis in children.

• Dystrophic dwarvenism.
• Mucopolysaccharidosis (for example, Morquio disease).
• Spondyloepiphysar dysplasia.
• Multiple epiphyseal dysplasia.
• Achondroplasia.

X. Scoliosis in children on the basis of osteomyelitis.

XI. Metabolic disorders.

• Rickets.
• Imperfect osteogenesis.
• Homocystinuria.

XII. Scoliosis in children on the basis of the pathology of the lumbosacral articulation,

• Spondylolysis and spondylolisthesis.
• Congenital anomalies of the lumbosacral articulation.

XIII. Scoliosis in children on the basis of tumors.

• A. The spinal column.
  • Osteoid osteoma.
  • Histiocytosis X.
  • Others.
• B. Spinal cord.

The term "idiopathic" as applied to scoliosis as a nosological unit means that its origin at this stage in the development of medical science remains unknown. Since Hippocrates first introduced the clinical description, and Galen proposed a number of terms for determining the deformation of the spine (scoliosis in children, kyphosis, lordosis, strophosis), thousands of years have passed, but there is no single point of view on the root cause of idiopathic scoliosis. There are many proposals and hypotheses, some of them are hopelessly outdated (scoliosis in children of the school period, rickets scoliosis in children) and deserve no more than a mention.

Studies of vertebral and paravertebral structures made it possible to reveal numerous morphological and chemical changes in the tissues. However, in no case was there any reason to state categorically that the noted deviations from the norm are the reason for the development of scoliotic deformation, and not the consequence of its drinking.

The hormonal status of patients with scoliosis was repeatedly investigated - deviations in the functioning of the pituitary-adrenal system and the adrenal cortex proper were detected, changes in the content of sex hormones were revealed.

M.G. Dudin investigated in patients with scoliosis the content of osteotropic hormones of direct action (calcitonin, parathyre, somatotropin and cortisol). The non-progressive course of idiopathic scoliosis was noted at high concentrations of cortisol and parathyrin. Progression of scoliosis in children in the opposite ratio: a high content of calcitonin and somatotropin. By M.G. Dudin, the growth of the spine is affected by two systems - the nervous and endocrine. An increase in the synthesis of hormones stimulates the growth of the spine, which creates unfavorable conditions for the spinal cord. Because of the peculiarities of the anatomical relationship between the bone structures of the spine and the spinal cord, a situation arises where the anterior sections of the spinal column are longer than the posterior ones. Compensation of this condition, which arose as a result of the imbalance of the action of the nervous and endocrine systems, occurs due to the twisting of the elongated anterior sections of the spine around the relatively shortened posterior ones. Clinically and radiographically, this is manifested by the torsion of the vertebrae.

Dysfunction of the nervous and endocrine systems becomes the trigger mechanism for the development of idiopathic scoliosis and in accordance with Sevasllk theory. It is based on the dysfunction of the sympathetic nervous system. As a result, hyperemia of the left half of the thorax develops, as a result of which the ribs on this side begin to grow rapidly. It is the asymmetric growth of the ribs that causes a gross deformation of the chest and spine. Sevastik emphasizes that in relation to the deformation of the rib cage of the chest, the scoliosis proper in children is secondary.

In recent years, there are reports of the family nature of idiopathic scoliosis. In various studies, models of inheritance of idiopathic scoliosis are suggested: multifactorial, sex-linked inheritance, autosomal dominant inheritance of the disease with incomplete penetrance of genotypes. Several attempts have been made to identify the gene responsible for the development of idiopathic scoliosis. The structural genes of extracellular matrix components were considered as applicants: elastin, collagen and fibrillin. However, none of the genes demonstrated adhesion to the sex, responsible for the development of the disease. Thus, the mechanisms of inheritance of idiopathic scoliosis have not yet been established.

It is known that there are sex differences in the manifestation of this disease. It is diagnosed in girls much more often than in boys.

The ratio of the sexes among patients with idiopathic scoliosis varies from 2: 1 to 18: 1. Moreover, polymorphism increases with increasing severity of the disease. This makes the analysis of inheritance of idiopathic scoliosis especially difficult.

Studies have shown that in all groups of relatives the purity of idiopathic scoliosis is significantly higher than the average for the population. This confirms the known data on the family aggregation of the pathology studied. In addition, it turned out that the frequency of scoliosis among sisters of probands is higher than among the brothers. This also agrees well with the known data. At the same time, there were no significant differences in the incidence of idiopathic scoliosis in the fathers and mothers of probands.

Segregation analysis has shown that the inheritance of expressed (II-IV degree) scoliosis can be described within the framework of an autosomal dominant majorgen dialect model with incomplete penetrance of genotypes, depending on sex and age. At the same time, the penetrance of genotypes bearing a mutant allele is about twice as high in girls as in boys. This is in good agreement with the known data on the incidence of idiopathic scoliosis in children. If the existence of the major was able to be proved with a high degree of reliability, it can be expected that further research will allow localizing it and finding the possibility of influencing the majorogen in order to prevent the development of the pathological process.

[15], [16], [17], [18], [19], [20], [21]

How is scoliosis diagnosed in children?

In pediatric practice, the timely diagnosis of idiopathic scoliosis is of paramount importance. This is a severe orthopedic disease, expressed in the multiplanar deformation of the spine and thorax. The term "idiopathic" implies a cause unknown to modern science of the origin of the disease. However, an important role in predisposition to this type of scoliosis is played by various signs of dysplastic development of the skeleton and their combination: vertebral hypoplasia, violation of segmentation, bone dysplasia of the lumbosacral spine, underdevelopment or asymmetry of development of XII pairs of ribs, abnormalities of teeth and bite development, asymmetry and abnormalities in the development of the skull, flat feet, etc. When attentively neurological examination determine the deviation in tendon-muscle reflexes, which may indicate my odisplasticheskih processes. The identification of these signs allows us to talk about the dysplastic nature of idiopathic scoliosis.

The full interpretation of the diagnosis of "scoliosis in children" requires the definition of the etiology, localization and orientation of the arc of curvature of the spine, as well as the severity of scoliosis.

X-ray examination

Radiography of the spine is performed in a straight and lateral projection. Standing. According to the X-ray patterns, the localization of the curvature arc is determined, its magnitude is measured, the degree of pathological rotation (from the projection of the bases of the arcs of the vertebra), the shape and structure of the vertebral bodies and intervertebral discs, reveals dysplastic signs of bone tissue development, assesses the degree of osteoporosis, bone age (according to the degree of ossification of the apophyses of the body vertebrae) to determine the prognosis of the further course of the disease. X-ray functional research is conducted to determine the stability or mobility of deformation. It is important to know also for determining the prognosis of the disease and indications for further treatment.

Differential diagnostics

The initial idiopathic scoliosis in children must first of all be differentiated from the violation of posture in the frontal plane. In this case, the cardinal distinctive feature is the presence of pathological rotation and torsion of the vertebrae in scoliosis, and clinically the appearance of a rib humerus and muscular cushion. In addition, idiopathic scoliosis in children should be distinguished from spinal deformities caused by other diseases: congenital scoliosis in children, neurogenic scoliosis, scar scoliosis after operations on the chest and burns, scoliosis against systemic hereditary diseases.

Congenital scoliosis develops as a result of developmental defects in the vertebrae, which determine radiographically.

The most common anomaly is lateral wedge-shaped vertebrae and semi-vertebra. They can be found in any part of the spine, but more often in transitional ones, they are single and multiple. Sometimes this anomaly is combined with other malformations of the vertebrae and spinal cord. If the lateral half-vertebrae are on one side, the curvature becomes rapidly pronounced, rapidly progressing, and indications for surgical treatment arise, since such deformation can lead to neurologic motor disorders due to compression of the spinal cord.

If the semi-vertebrae are located on opposite sides or the semi-vertebrae fuses with the above and below normal normally developed vertebrae (ie, the bone block forms), the course of scoliosis in such cases is more favorable.

[22], [23], [24], [25], [26], [27], [28], [29]

How is scoliosis treated in children?

The goal of conservative treatment of scoliosis is to keep the spinal deformation from further progression. Principles of treatment: axial unloading of the spine and the creation of a strong muscular corset due to the use of physical methods of treatment. Curative gymnastics - a special set of exercises, corresponding to an individual diagnosis, performed first outpatiently, under the supervision of the LFK methodologist, and then at home for 30-40 minutes. Assign a massage of the muscles of the back and abdomen (2-3 courses per year for 15 sessions). Recommend regular swimming style "breaststroke". Physiotherapy treatment includes electrophoresis of drugs to improve spinal cord trophism, bone and near-vertebral soft tissues in the region of the main arc of curvature, electromyostimulation on the convex side of the deformation. To unload the spine, when necessary, you can use ready-made orthopedic corsets. For the treatment of progressive scoliosis, curative corsets of the Chenot type are currently used in the world practice.

Complex conservative treatment is carried out in a polyclinic at the place of residence, in specialized kindergartens or boarding schools, in sanatoria for children with disorders and diseases of the musculoskeletal system.

Surgical treatment of scoliosis

Its goal is the maximum possible correction of the deformed spine and its lifelong stabilization in conditions of a normal balance of the trunk. For surgical treatment, various technologies are used depending on the localization and severity of the curvature (including with the use of corrective metal structures and osteoplastic fixation of the spine).

The optimal age for surgical treatment is 15-16 years, when the growth potential is reduced and the risk of loss of correction is minimal.

How to prevent scoliosis in children?

Given the ambiguity of the cause of scoliosis, there is no specific prevention. However, if the child has a violation of posture, it shows the conduct of courses of therapeutic physical training, general strengthening massage and regular swimming. In classes in pre-school institutions and schools, teachers should monitor the child in terms of maintaining a correct posture.

What prognosis does scoliosis have in children?

The prognosis of the course of scoliosis depends on the totality of anamnestic, clinical and radiological signs. The earlier the scoliosis is manifested for the first time in children, the more progressing it acquires. Thoracic scoliosis is less favorable than lumbar scoliosis. Scoliosis in children as much as possible progresses at pubertal age, and after the end of spine growth (complete ossification of apophyses of the vertebrae), the curvature stabilizes.

Idiopathic scoliosis in children is inherited in rare cases (6-8%).

With adequate conservative treatment conducted before the child's growth, scoliosis in children has a more favorable prognosis.