Scoliosis of the lumbar spine

Lumbar spine curvature – lumbar scoliosis – often develops as a compensatory reaction to primary deformation of the thoracic spine, or is formed primarily. The pathology is characterized by a unilateral shortening of the lower limb, as well as pronounced asymmetry of the waist area. The problem develops slowly, can be corrected in the early stages, but in advanced stages it can cause the development of serious complications. [ 1 ]

Epidemiology

Currently, scoliosis is a fairly common disorder. Doctors voice disappointing prognoses and say that the problem will only worsen over the years, which is due to the relatively sedentary lifestyle of modern youth, prolonged sitting at the computer, poor nutrition, etc.

It is in schoolchildren at the stage of active formation of the musculoskeletal system that the overwhelming majority of cases of scoliosis appear. In some patients, the pathology remains forever and only progresses over the years.

Fortunately, modern diagnostic methods make it possible to detect pathological curvature even at the stage of absence of clinical manifestations.

According to general statistics, lumbar spinal deformities are extremely common, especially in European countries and the United States. A slightly lower incidence is observed in African and Asian countries, where the level of education is clearly lagging behind. Here, children spend less time at tables and desks, but move much more. But it is precisely a sedentary lifestyle and prolonged improper sitting at a desk that are considered the main factors in the formation of spinal deformities. The prevalence of lumbar scoliosis among the adult population ranges from 2% to 32%; a recent study involving elderly volunteers showed a prevalence of over 60%. [ 2 ], [ 3 ] The prevalence of degenerative lumbar scoliosis ranges from 6% to 68%. [ 4 ], [ 5 ]

Girls suffer from lumbar scoliosis almost 5 times more often than boys. Experts explain this fact by the fact that girls are less involved in sports activities, but spend more time studying.

Among all types of scoliosis curvatures, the most common is thoracolumbar scoliosis: it is found in 4 out of 10 patients who have spinal deformity.

Approximately 15% of patients are diagnosed with lumbar scoliosis only, which in most cases is asymptomatic and almost never complicated (complications are observed in only 3% of cases).

Causes lumbar scoliosis

Lateral deformation of the lumbar segment of the spinal column can be caused by the following reasons:

• congenital defects of the spine;
• genetic pathologies;
• traumatic injuries, including fractures, displacements, etc.;
• postoperative complications;
• bone tuberculosis;
• physical inactivity, passive lifestyle;
• improperly organized sleeping and working space (which especially concerns children);
• degenerative processes affecting the musculoskeletal system, osteoporosis;
• rheumatism;
• endocrine diseases;
• excess weight, overweight;
• tumors affecting the back and spinal column;
• intervertebral herniated discs;
• unequal length of lower limbs, abnormal foot shape (flat feet, etc.);
• cerebral palsy, syringomyelia;
• psychogenic disorders;
• metabolic disorders.

The disorder most often develops during the period of bone growth – that is, in childhood and adolescence. In this case, the first place is occupied by idiopathic scoliosis – a curvature, the causes of which cannot be determined.

Risk factors

The most common risk factors are considered to be congenital defects:

• degenerative changes in the vertebral arches;
• semivertebrae;
• underdeveloped lower segment of the spinal column;
• inappropriate number of vertebrae in the lumbar and sacral regions (lumbarization);
• birth injuries.
• In approximately 80% of cases of nonidiopathic scoliosis, risk factors include;
• overweight;
• traumatic back injuries;
• cerebral palsy, foot deformities, rheumatism;
• physical inactivity, passive lifestyle, weakness of the muscular corset;
• pregnancy period.

The risk group includes school-age children, students, office workers who are forced to sit at a desk or table for a long time. However, the problem would not arise so often if the workplace were properly organized.

Pathogenesis

The spine includes 32-34 vertebrae. The spinal section is represented by 5 vertebrae L1-L5.

The vertebrae of different sections have different shapes, which is due to their different purposes and functions. Normally, the spinal column has four physiological curvatures. Specifically, in the lumbar region, there is kyphosis - a bulge towards the back. Due to this curvature, spinal flexibility is formed. [ 6 ]

Some traumatic, degenerative or age-related spinal lesions lead to the fact that, in addition to physiological, pathological curvatures also appear. In adulthood, the most common causes are degenerative-dystrophic processes, loss of bone mass (osteoporosis), bone softening (osteomalacia). In some people who have undergone spinal surgery, scoliosis becomes an unfavorable postoperative consequence. [ 7 ]

Degenerative deformation is usually diagnosed in patients over 40-45 years of age. Among older people, and especially among women, the disorder often develops against the background of osteoporosis. With a combination of these pathological factors, the spinal column loses the ability to maintain a normal position and becomes curved. [ 8 ]

In degenerative processes, the spinal column loses its structural stability and balance. With an increase in the angle of the scoliosis arc, degeneration of the spine increases, which is interconnected. Gradual narrowing of the intervertebral discs, wear of cartilage and articular surfaces, back pain are noted. [ 9 ]

Symptoms lumbar scoliosis

Lumbar scoliosis is accompanied by noticeable changes throughout almost the entire body: a person's shoulder drops, a stoop develops, the pelvic area becomes curved, and the lower limbs become uneven. As the scoliosis arc increases, the signs become more obvious, a crunching sound occurs while walking, pain and paresthesia appear.

The first signs do not appear immediately: at first, a slight stoop is noted, which is difficult for a non-specialist to notice. Then other symptoms appear, which can already be paid attention to:

• the shoulders become asymmetrical (located at different levels);
• head tilts to the side;
• visually, an arc of deformation is noticeable from the back;
• the hips are of different heights;
• I often suffer from lower back pain;
• the ribs on one side are more convex;
• digestive disorders appear;
• intercostal neuralgia often bothers me;
• weakness and numbness of the limbs may appear.

Pain in lumbar scoliosis is one of the first signs of the disorder. The pain is nagging in nature, localized in the lower spine, and as the process progresses, patients note pain in the hips, groin, sacroiliac joints, knee joint, ankle, foot, and Achilles tendon. As the deformation worsens, the internal organs shift, their function is disrupted, and the pain syndrome intensifies. [ 10 ]

When pelvic tilt occurs, the symptoms expand. The following appear:

• hip pain when walking, lameness, tendency to fall;
• motor stiffness;
• different lengths of lower limbs;
• dysfunction of the urinary system, genitals and intestines;
• muscle imbalance (atrophy of some muscles against the background of overstrain of others).

Lumbar scoliosis and pelvic tilt lead to an imbalance of the trunk: there is a gradual tilt of the trunk axis towards the apex of the curvature. [ 11 ]

Lumbar scoliosis in children

In order to determine the symptoms of lumbar deformity in a child, parents themselves can perform a small diagnostic test. The child is asked to stand up straight, relax the muscles, and let their arms hang freely along the body. It is necessary to pay attention to the uniformity of the protrusion of the collarbones, shoulder blades, and the uniformity of the height of the shoulders. At the next stage, the child may have a distortion of the torso, especially noticeable when bending forward. With a large degree of curvature, the curved arc of the spine becomes noticeable to the naked eye.

In the early stages of the pathology, the problem is practically not manifested externally: the diagnosis is established by a specialist based on X-ray images.

Scoliosis is found in children quite often. And there are a number of explanations for this. Firstly, the child's body grows and develops rapidly, and many organs and systems do not always have time to "catch up" with neighboring structures in development. It is with such a confluence of events that favorable conditions are created for the development of spinal curvature. Rapid growth of bone structures against the background of slow growth of the ligament-muscle apparatus leads to disproportionate loads on the spine. As a result - the appearance of deformation. [ 12 ]

Another factor influencing the emergence of the problem is increased loads on the spine, which is not yet strong. Young schoolchildren are forced to carry quite heavy school bags and backpacks, sit at a desk for a long time (not always functional and comfortable). All these reasons can be leveled if you pay attention to them in a timely manner.

Stages

The clinical picture of lumbar scoliosis depends on the stage of the disorder. Thus, 4 stages of pathology development are known, the main criterion of which is the angle of deformation.

• Lumbar scoliosis of the 1st degree is often not accompanied by any symptoms. Discomfort can be expressed in periodic headaches, general weakness, back fatigue, slight pain in the lower back (especially after routine work). Only a doctor can determine the curvature externally. In some cases, it is necessary to conduct an X-ray or MRI.
• Lumbar scoliosis of the 2nd degree is characterized by a visible angle of deviation within 11-25°. If you ask the patient to lean forward, you can detect a slight asymmetry of the spinal column, different levels of the location of the shoulder blades and hips. The patient complains of pain when trying to rotate the torso.
• Lumbar scoliosis of the 3rd degree is characterized by the appearance of an arc of curvature within 26-50°. The external manifestation of the deformation is clear, a pronounced rib hump becomes noticeable. The patient complains of regular pain and limited mobility.
• Lumbar scoliosis of the 4th degree is accompanied by an increase in the deformed arc of more than 50°. We are talking about advanced curvature of the spinal column.

Forms

Doctors distinguish the following variations of lumbar scoliosis:

• Idiopathic lumbar scoliosis is a curvature whose cause cannot be determined. According to statistics, such deformations account for 80% of all detected ones.
• Dysplastic lumbar scoliosis is the most severe variant of the course of deformation, caused by congenital pathology of the development of the corresponding section of the spine. The disease is associated with a violation of metabolic processes and blood supply to the tissues of the vertebrae and discs.
• Degenerative scoliosis of the lumbar spine is a pathology caused by degenerative-dystrophic lesions, osteoporosis (loss of bone mass), osteomalacia (bone softening). This type of pathology is more typical for people over 40-45 years old. [ 13 ]
• Thoracolumbar scoliosis is a curvature with its peak at the level of the Th11-Th12 vertebrae.
• Lumbosacral scoliosis is a curvature with the apex at the level of the L5-S1 vertebrae.
• Lumbar C-shaped scoliosis is a deformation with one arc of curvature with the apex at the level of the L1-L2 vertebrae.
• Left-sided lumbar scoliosis is more typical for left-handers: anatomical disorders of the vertebrae and the support mechanism to the left are noted. Accordingly, the arc of curvature is diverted to the left, which becomes noticeable during external examination.
• Right-sided lumbar scoliosis is accompanied by a deviation of the spinal column (vertebrae and supporting structures) to the right. Right-sided curvature is more common than left-sided.

Complications and consequences

Lumbar scoliosis can cause a lot of complications from the internal organs. This is due, in particular, to a change in the location of certain organs on the deformed side. The urinary, digestive, reproductive systems, and blood circulation are most often affected.

Already some time after the formation of a scoliosis arc in the human body, the risk of developing irreversible changes in the cardiovascular system increases significantly. Arterial blood flow does not receive enough oxygen, the internal size of some heart chambers increases, and a condition similar in symptoms to pulmonary heart failure occurs. Even after correction of the scoliosis deformity, cardiac activity indicators no longer return to normal. And this consequence is far from the only one. [ 14 ] Among the most common complications:

• chronic pain syndrome;
• disorders of the digestive and genitourinary systems, systematic intestinal flatulence, constipation;
• infertility in women, congestion in the pelvic area;
• nerve entrapment, paresis and paralysis;
• development of cascade fractures; [ 15 ]
• swelling of the lower extremities;
• weakening of the tone of the abdominal wall muscles;
• psychological disorders, depression, neuroses caused by defects in appearance.

As a result of the compression of blood vessels against the background of vertebral artery syndrome, cerebral blood supply deteriorates, which in childhood manifests itself in memory and thought process impairment. Children have difficulties with learning. [ 16 ]

Neurological symptoms often appear in adolescence.

Can a child's lumbar scoliosis disappear?

Curvature at an early stage can be corrected if you follow simple recommendations from specialists. For example, it is important to explain to the child how important it is to take breaks from work, and during recess not to stay at the desk, but to stand up, walk or run, stretch, bend the body a few times. Even a couple of exercises will help keep the back muscles in good shape.

Another important condition is to carry not a briefcase or backpack, but a special satchel with an orthopedic back. All accessories in it should be folded evenly and neatly, and not chaotically. Overloading the back should be avoided, but carrying a briefcase in your hands or on one shoulder is also not recommended: this can cause a worsening of the spine misalignment.

The sooner measures are taken to eliminate the deformation, the greater the chances of recovery. In addition, manual therapy and therapeutic exercises should be included. Only in this case can we expect correction of the pathology. [ 17 ]

Hernias in lumbar scoliosis

A hernia is a kind of squeezing of the intervertebral disc out of the fibrous ring as a result of its rupture. A spinal column weakened by curvature often acquires such hernias, and this complication is difficult to avoid. [ 18 ]

A hernia in lumbar scoliosis has its own characteristics: the protrusion is directed into the intervertebral canal, presses on the nerve ending, and acute pain syndrome develops. In such a situation, it is not enough to simply relieve the pain. Against the background of curvature, the hernia will continue to increase, so the symptoms will again make themselves known, and the clinical picture will become more diverse:

• severe pain will appear, caused by extensive irritation of nerve fibers;
• the lower limbs will regularly go numb, up to the development of tissue dystrophy;
• you will be bothered by swelling, fatigue in the legs, pain;
• the functioning of the digestive tract (in particular, the intestines) and urinary system will be disrupted.

Both scoliosis and hernia are curable conditions if diagnosed in a timely manner and treated adequately. However, advanced cases are difficult to treat or cannot be treated at all, and the patient becomes disabled. [ 19 ]

Sacralization of the lumbar spine in scoliosis

Sacralization is a congenital defect of the spinal column in which the fifth lumbar vertebra is somewhat fused to the sacrum. This pathology often accelerates the development of osteochondrosis or spondyloarthrosis. [ 20 ]

Sacralization is accompanied by increased pressure on the lumbar segments that are located above the fusion site. With normal average load, the spinal column copes with its tasks, but with increased pressure on the vertebrae (for example, with lumbar scoliosis), the congenital disorder makes itself known.

The pathology can manifest itself on the right, left, or both sides of the vertebra. Partial fusion is observed in the cartilaginous and articular forms of the disease, and complete fusion occurs with bone sacralization. [ 21 ]

Expressed clinical symptoms in scoliosis with sacralization are rare, the general well-being of the patient is practically not affected. If symptoms are present, then the only method of treatment is considered to be surgical intervention, although in practice, the help of a surgeon is extremely rare.

Diagnostics lumbar scoliosis

During diagnostic procedures, the doctor listens to the patient's complaints. In particular, he/she pays attention to the presence of pain along the spinal column, a feeling of back fatigue, muscle weakness, and posture disorders. The anamnesis should include information about the time of the first signs of the disorder, previous pathologies, and complaints during periods of intensive growth of the child.

During the examination, the doctor pays attention to postural disorders, curvature of the spinal column, asymmetry of the shoulders, angles of the shoulder blades, triangles of the waist and axis of the iliac bones, as well as the presence of a costal hump.

Palpation reveals the presence of pain along the spine.

Laboratory tests are non-specific but may be prescribed as part of general examinations. In some cases, clinical, biochemical blood tests with assessment of phosphorus and calcium levels, as well as clinical urine tests are required.

Instrumental diagnostics include radiography of the spine in two projections (regardless of the form of deformation), functional radiography of the thoracolumbar spine with a tilt to the left and right (especially relevant for idiopathic scoliosis). Additionally, magnetic resonance imaging of the spine is prescribed to exclude syringomyelitic cystic formations, hemivertebrae, spinal cord disorders, diastomyomyelia. Computed tomography of the spine is performed to exclude synostosis of the vertebral bodies, additional hemivertebrae. [ 22 ]

Differential diagnosis

Differential diagnosis is carried out in the presence of corresponding symptoms:

• If postural disorders, rib hump, and motor limitations are present against the background of a negative Mantoux reaction, then the pathology is differentiated from other types of scoliosis.
• If there is a reference to spinal injuries, kyphosis without limitation of mobility with a negative Mantoux test, then the pathology is differentiated from juvenile kyphosis - Scheuermann-Mau disease.
• In the presence of a primary tuberculous lesion, a positive Mantoux reaction and limited motor activity, the pathology is differentiated from tuberculosis of the spine.

Treatment lumbar scoliosis

Depending on the severity of the pathological deformation and the patient’s age, the doctor may prescribe either conservative (in most cases) or surgical treatment of lumbar scoliosis.

Prevention

In most cases, lumbar scoliosis begins to develop in primary school age. The most common causes are: poor posture, weakness of the muscular corset and ligamentous apparatus - especially in children who do not play sports and do not have the opportunity to additionally strengthen the back muscles. Both at school and at home, the child sits at the table for a long time, not monitoring his posture, so most schoolchildren already acquire scoliosis in elementary school.

To avoid the development of this disorder, it is necessary to teach the child from early childhood to correct posture, even distribution of the load on the back. An important preventive step is physical exercise. It is good if the child regularly attends a sports section or does morning exercises every day. Simple exercises that work the thoracic, lumbar and cervical spine are enough.

Another important preventive condition is wearing a comfortable school bag (not a briefcase or backpack, but a school bag with a rigid back). One-sided shoulder bags are especially not recommended. It is also necessary to monitor the student's gait and prevent slouching.

All of the above advice is also relevant for adults, not only in terms of prevention, but also to prevent further worsening of an existing curvature.

Among sports, swimming is considered the most beneficial for the back. It is both a pleasant pastime and an excellent way to relieve excess tension in the spinal column. It is advisable to train with an instructor. Thanks to regular training, there is a strengthening of the back muscles, straightening of scoliosis in the early stages of development. A good effect is noted from aqua aerobics, which strengthens the body and at the same time is practically not characterized by increased trauma.

Forecast

If the basic preventive and therapeutic recommendations are neglected, the curvature of the spine in most cases progresses, accompanied by a violation of the normal mutual arrangement of internal organs. Physical disability, blood supply disorders due to displacement of the vascular network, neurological disorders due to pinching of nerve fibers and endings, functional problems with the liver, kidneys, pancreas, and reproductive system may occur.

Cosmetic curvature defects have a negative impact on the psyche, which can provoke serious suffering of the patient, up to the development of depressive states, neuroses and psychoses. However, lumbar scoliosis, detected at the initial stages of development in childhood, is easily corrected and can be corrected in a relatively short time, provided that all medical recommendations are followed.