Scoliosis. Deformations of Scoliosis. Deformations of the neck, chest. Clinic, the neck, chest. Clinic, diagnosis and treatment.diagnosis and treatment.

PROFESSOR PROFESSOR

Fishchenko Vladimir AlexandrovichFishchenko Vladimir Alexandrovich

BASHINSKIY GENNADIY BASHINSKIY GENNADIY PETROVICHPETROVICH

Scoliosis (Scoliosis) - a serious Scoliosis (Scoliosis) - a serious disease of the musculoskeletal disease of the musculoskeletal system, represented by the system, represented by the curvature of the spine in the frontal curvature of the spine in the frontal plane and twisting around its plane and twisting around its vertical axis (SARS), which vertical axis (SARS), which manifests itself at a young age and manifests itself at a young age and progresses with the growth of the progresses with the growth of the organismorganism

Depending on the age of the appearance of Depending on the age of the appearance of strains of scoliosis are the following:strains of scoliosis are the following:

Infantile (diagnosed before 3 years of age) Infantile (diagnosed before 3 years of age) (Infantile)(Infantile)Juvenile (diagnosed from 3 years to 10 Juvenile (diagnosed from 3 years to 10 years) (Juvenile)years) (Juvenile)Junior (diagnosed between 10 and 15 Junior (diagnosed between 10 and 15 years) (Adolescent)years) (Adolescent)Scoliosis in adults (diagnosed in adulthood, Scoliosis in adults (diagnosed in adulthood, after the termination of growth) (Adultafter the termination of growth) (Adult) )

skeletal changes in scoliosis, skeletal changes in scoliosis, depending on agedepending on age

Of the numerous classifications of Of the numerous classifications of scoliosis in accordance with the scoliosis in accordance with the etiology and pathogenesis of etiology and pathogenesis of most widespread use most widespread use classification received Cobb classification received Cobb (1958), according to which they (1958), according to which they are distributed into five main are distributed into five main groups.groups.

The first group - myopathic scoliosis . The first group - myopathic scoliosis . BBasicallyasically on these on these curvatures of the curvatures of the spine is insufficient development of spine is insufficient development of muscle tissue and ligaments. This muscle tissue and ligaments. This group can be assigned and rachitic group can be assigned and rachitic scoliosis, which arise as a result of scoliosis, which arise as a result of degenerative process not only in the degenerative process not only in the skeleton, but also in the skeleton, but also in the neuromuscular tissue.neuromuscular tissue.

The second group - scoliosis neurogenic The second group - scoliosis neurogenic origin: on the basis of origin: on the basis of neurofibromatosis, syringomyelia, neurofibromatosis, syringomyelia, spastic paralysis. In the same group may spastic paralysis. In the same group may be included scoliosis and be included scoliosis and lyumboishialgii caused by degenerative lyumboishialgii caused by degenerative changes in the intervertebral discs, changes in the intervertebral discs, often leading to compression of the often leading to compression of the roots and cause clinically hetero-orroots and cause clinically hetero-or--gomo radicular syndromegomo radicular syndrome

The third group - scoliosis on the The third group - scoliosis on the basis of of developmental basis of of developmental abnormalities of the vertebrae abnormalities of the vertebrae and ribs. This group includes all and ribs. This group includes all congenital scoliosis, which is congenital scoliosis, which is associated with the occurrence of associated with the occurrence of bone dysplastic changes.bone dysplastic changes.

The fourth group - scoliosis The fourth group - scoliosis caused diseases of the chest caused diseases of the chest (scar after(scar after empyema o empyema orr burns, burns, plastic surgery on the chestplastic surgery on the chest

- The fifth group idiopatic - The fifth group idiopatic scoliosis, the origin of which scoliosis, the origin of which currently is still far from currently is still far from understood.understood.These scoliosis found in the These scoliosis found in the greatest number of peoplegreatest number of people

By the degree of By the degree of scoliosis deformation scoliosis deformation divideddivided I degree scoliosis is characterized by I degree scoliosis is characterized by

small lateral deviation of the spine small lateral deviation of the spine and the initial degree of torsion, and the initial degree of torsion, radiographically detectable. Torsion radiographically detectable. Torsion on the radiograph is defined as a small on the radiograph is defined as a small deviation of the spinous processes of deviation of the spinous processes of the midline and the lack of symmetry the midline and the lack of symmetry of the roots of the arches. Angle of the of the roots of the arches. Angle of the primary arc of curvature less than 10 °primary arc of curvature less than 10 °

Scoliosis II degree is accompanied not Scoliosis II degree is accompanied not only noticeable deviation of the spine only noticeable deviation of the spine the frontal plane, but also expressed the the frontal plane, but also expressed the rotation, the presence of compensatory rotation, the presence of compensatory arcs. Radiographically clearly manifested arcs. Radiographically clearly manifested deformation of vertebral bodies at the deformation of vertebral bodies at the level of the top of the curve. Angle of the level of the top of the curve. Angle of the primary arc of curvature in the range 21-primary arc of curvature in the range 21-30 °. Clinically defined muscle roller 30 °. Clinically defined muscle roller because torsion of the spine and rib because torsion of the spine and rib hump.hump.

III degree scoliosis is characterized by III degree scoliosis is characterized by persistent and more severe persistent and more severe deformation, the large rib hump, deformation, the large rib hump, deformity deformity of theof the chest. Angle of the chest. Angle of the primary arc of curvature from 40 to 60 primary arc of curvature from 40 to 60 °. Radiographically on top curvature °. Radiographically on top curvature and adjacent areas are wedge-shaped and adjacent areas are wedge-shaped vertebrae, intervertebral discs with vertebrae, intervertebral discs with the concave side of hard tracedthe concave side of hard traced

Scoliosis IV degree accompanied by severe Scoliosis IV degree accompanied by severe deformation of the body. Marked deformation of the body. Marked kyphoscoliosis of the thoracic spine, kyphoscoliosis of the thoracic spine, deformity of the pelvis, the deviation of the deformity of the pelvis, the deviation of the body, stiffness in the spine, fixed deformity body, stiffness in the spine, fixed deformity of the chest, back and front rib hump. of the chest, back and front rib hump. Determined radiographically pronounced Determined radiographically pronounced sphenoid deformation bodies of the thoracic sphenoid deformation bodies of the thoracic vertebrae, and spondylosisvertebrae, and spondylosis,, deformans deformans spondylarthrosis in the thoracic and lumbar spondylarthrosis in the thoracic and lumbar spine, calcification of ligamentous apparatus. spine, calcification of ligamentous apparatus. Corner of the main curvature reaches 61-90 °Corner of the main curvature reaches 61-90 °

ССlassification of lassification of scoliosis by Chaklinscoliosis by Chaklin Curvature of the spine are divided Curvature of the spine are divided

into four levels (by Chaklin)into four levels (by Chaklin)when I degree angle of curvature when I degree angle of curvature - 180-175 °;- 180-175 °;with II degree - 175-155 °;with II degree - 175-155 °;with III degree - 155-100 °;with III degree - 155-100 °;with IV degree - less than 100 °with IV degree - less than 100 °

How to define scoliosisHow to define scoliosis

Congenital form of scoliosis in the Congenital form of scoliosis in the early stages is almost impossible to early stages is almost impossible to determine. It must notice at determine. It must notice at regular examinations regular examinations by by orthopedist. Orthopedist should orthopedist. Orthopedist should prescribe intensive orthopedic prescribe intensive orthopedic treatment. Thus, we can stop the treatment. Thus, we can stop the development of scoliosis to severe development of scoliosis to severe stages.stages.

If a child is already on his feet, If a child is already on his feet, parents can also do a little parents can also do a little diagnosis, which will help diagnosis, which will help determine whether there is a determine whether there is a violation in posture. There are violation in posture. There are five such points, which will help five such points, which will help them to see the lateral curvature.them to see the lateral curvature.

First, the shoulders are at different First, the shoulders are at different heights. Second, the uneven position of heights. Second, the uneven position of the lower corners of the blades. To the lower corners of the blades. To define it is necessary to bring your define it is necessary to bring your fingers under the blade and see at what fingers under the blade and see at what level they are located. Third, the level they are located. Third, the presence of lateral folds of the stomach, presence of lateral folds of the stomach, on one side of the body deeper one on one side of the body deeper one pleat, and on the other side of the fold is pleat, and on the other side of the fold is absent.absent.

Fourth - different levels of sacral Fourth - different levels of sacral dimples. Fifth - when you lean dimples. Fifth - when you lean forward or when lying down spinal forward or when lying down spinal curvature is maintained. This curvature is maintained. This manifestation is absent in scoliotic manifestation is absent in scoliotic postureposture

Treatment of severe curvature of the Treatment of severe curvature of the spine is very difficult. Expect a spine is very difficult. Expect a significant correction of deformation significant correction of deformation is possible only with scoliosis I is possible only with scoliosis I degree. Treatment usually must be degree. Treatment usually must be started as soon as the first signs are started as soon as the first signs are found curvature of the spinefound curvature of the spine

Modern methods of treatment of Modern methods of treatment of scoliosis can be reduced to three scoliosis can be reduced to three main points: the mobilization of the main points: the mobilization of the spine, deformity correction and spine, deformity correction and retain the achieved correction. This is retain the achieved correction. This is achieved by means of physiotherapy, achieved by means of physiotherapy, special corsets, or combined special corsets, or combined methodsmethods

The main method of treatment of The main method of treatment of scoliosis currently accepted scoliosis currently accepted combination.combination.Gymnastics in regular Gymnastics in regular employment for several years employment for several years increases muscle tone and makes increases muscle tone and makes the muscles able to resist the muscles able to resist deformationdeformation

Exercises must be carried out in the Exercises must be carried out in the clinic and make sure the house where clinic and make sure the house where treatment is considered basic. The clinic treatment is considered basic. The clinic only studied complex, controlled quality only studied complex, controlled quality of its execution, introduce new of its execution, introduce new exercises. Basic exercises gymnastics exercises. Basic exercises gymnastics performed lying: strengthening those performed lying: strengthening those muscles that standing less loaded. muscles that standing less loaded. EExercisesxercises should spend at least 2 times should spend at least 2 times a day, morning and evening (at least 20-a day, morning and evening (at least 20-30 minutes per session).30 minutes per session).

CORSET CHENOTCORSET CHENOT

IIn world practice Corseting for over 30 n world practice Corseting for over 30 years is a major scientifically proven years is a major scientifically proven method of conservative treatment of method of conservative treatment of intermediate forms (II-III Art) scoliosis intermediate forms (II-III Art) scoliosis in children and adolescents. Using a in children and adolescents. Using a corset for scoliosis is the only non-corset for scoliosis is the only non-surgical method of treatment for surgical method of treatment for which there is scientific evidence for which there is scientific evidence for the effectivenessthe effectiveness

Indications for Indications for treatment corset treatment corset CHENOTCHENOT Angle of curvature of the arc before the onset Angle of curvature of the arc before the onset

of signs of puberty is 20 degrees.of signs of puberty is 20 degrees.In cases bending magnitude increases more In cases bending magnitude increases more than 20 degrees more than 5 degrees per than 20 degrees more than 5 degrees per year.year.With the amount of curvature of more than With the amount of curvature of more than 40 degrees and significant structural changes 40 degrees and significant structural changes in the vertebrae in patients of any age in the vertebrae in patients of any age unfavorable prognosis. In these cases, brace unfavorable prognosis. In these cases, brace therapy performed before the optimum therapy performed before the optimum moment for surgery.moment for surgery.

Funnel breastFunnel breast

Funnel chest (chest "cobbler") may Funnel chest (chest "cobbler") may be congenital or acquired. It is be congenital or acquired. It is characterized by a funnel-shaped characterized by a funnel-shaped recess the bottom of the chest wall recess the bottom of the chest wall and upper abdomen, deepening and upper abdomen, deepening crater and bend in the dorsal crater and bend in the dorsal direction xiphoid process of the direction xiphoid process of the sternum and costochondral sternum and costochondral junctions.junctions.

Classification depending on Classification depending on depth of the "funnel" and depth of the "funnel" and the degree of displacement the degree of displacement of the heartof the heart

There are three degrees of There are three degrees of deformation:deformation:I degree - depth "funnel" within 2 cm I degree - depth "funnel" within 2 cm without displacement of the heart.without displacement of the heart.Grade II - deformation depth of not Grade II - deformation depth of not more than 4 cm and displacement of more than 4 cm and displacement of the heart within 2-3 cmthe heart within 2-3 cmGrade III - deformation depth of more Grade III - deformation depth of more than 4 cm, and the displacement of the than 4 cm, and the displacement of the heart more than 3 cmheart more than 3 cm

Keeled chestKeeled chest

Characterized by an increase in the Characterized by an increase in the anterior-posterior diameter of the anterior-posterior diameter of the chestchestIn this case the sternum and xiphoid In this case the sternum and xiphoid sharply protrude. It gives a bird's sharply protrude. It gives a bird's view of the chest view of the chest

Treatment of Treatment of congenital deformities congenital deformities of the chestof the chest

Appointed by the general and special Appointed by the general and special exercises volleyball, basketball and exercises volleyball, basketball and swimming.swimming.In strengthening deformation and In strengthening deformation and increase functional changes of cardio increase functional changes of cardio - vascular system, the elimination of - vascular system, the elimination of which is possible only by surgery - by which is possible only by surgery - by thoracoplastythoracoplasty

Congenital high Congenital high scapulaescapulae Congenital high standing scapula Congenital high standing scapula

(Sprengel's deformity) - malformation, (Sprengel's deformity) - malformation, characterized in that one of the characterized in that one of the scapula 4-5 cm is above the other. At scapula 4-5 cm is above the other. At the same time it is rotated around the the same time it is rotated around the sagittal axis so that the lower angle of sagittal axis so that the lower angle of the scapula approached to spine, and the scapula approached to spine, and the outer edge is tilted downward. the outer edge is tilted downward. Treatment-operative.Treatment-operative.

Klippel-Feil diseaseKlippel-Feil disease

It is deformity of the cervical and It is deformity of the cervical and thoracic spine, which arises due to thoracic spine, which arises due to malformation of the cervical segment malformation of the cervical segment and is characterized by extensive and is characterized by extensive vertebral synostosis but arches have vertebral synostosis but arches have rupturerupture

Clinically - in patients with a short neck, Clinically - in patients with a short neck, sometimes it seems that it is absent. sometimes it seems that it is absent. The boundary of the scalp is so low that The boundary of the scalp is so low that the scalp goes to the scapula. Head the scalp goes to the scapula. Head tilted sharply to the side and anteriorly tilted sharply to the side and anteriorly so that the chin touches the chest. so that the chin touches the chest. Marked asymmetry of the face and Marked asymmetry of the face and skull, marked limitation of motion of the skull, marked limitation of motion of the cervical spine, scoliosis or kyphosis cervical spine, scoliosis or kyphosis marked, high standing shoulder girdle marked, high standing shoulder girdle and scapula.and scapula.

Grisel disease (torticollis Grisel disease (torticollis or rotational or rotational displacement of the displacement of the atlas)atlas) Grisel French doctor in 1930 described Grisel French doctor in 1930 described

the etiology and pathogenesis of this the etiology and pathogenesis of this disease, called it displacement of the disease, called it displacement of the atlas and nasopharyngeal torticollis.atlas and nasopharyngeal torticollis.Always precedes the appearance of Always precedes the appearance of deformation inflammatory disease in deformation inflammatory disease in the throat or nasopharynx, the throat or nasopharynx, accompanied by a high fever. After the accompanied by a high fever. After the disappearance of acute inflammation disappearance of acute inflammation remains the torticollisremains the torticollis

Grisel is explained displacement of Grisel is explained displacement of the atlas due to contracture of the atlas due to contracture of paravertebral muscles that attach to paravertebral muscles that attach to the front tubercle of the atlas and the front tubercle of the atlas and the skull and taking part in the the skull and taking part in the movement of the skull around the movement of the skull around the dens II cervical vertebradens II cervical vertebra

The disease occurs most often in The disease occurs most often in children, mainly in frail girls 6-11 children, mainly in frail girls 6-11 years old, weak muscle-ligament years old, weak muscle-ligament apparatus and features of the apparatus and features of the lymphatic system that contribute to lymphatic system that contribute to the deformation. The baby's head is the deformation. The baby's head is tilted in one side tilted in one side andand rotated in rotated in other sideother side

Treatment of this disease - anti-Treatment of this disease - anti-inflammatory therapy, inflammatory therapy, decontamination of the nasopharynx, decontamination of the nasopharynx, traction traction loop of Glisson loop of Glisson followed by followed by the imposition collar Schantzthe imposition collar Schantz

Congenital torticollisCongenital torticollis

Neck deformities which are characterized by Neck deformities which are characterized by incorrect head position - inclination to a side incorrect head position - inclination to a side and rotation - are united under the title and rotation - are united under the title “torticollis”.“torticollis”.

Most cases of congenital torticollis are of Most cases of congenital torticollis are of muscular and congenital origin.muscular and congenital origin.

Congenital muscular torticollis is one of the Congenital muscular torticollis is one of the most common orthopedic diseases in children. most common orthopedic diseases in children. According to most authors it takes the third According to most authors it takes the third place after congenital hip dislocation and place after congenital hip dislocation and clubfoot. The number of the disease increased clubfoot. The number of the disease increased last years.last years.

Muscular Torticollis On the Left SideMuscular Torticollis On the Left Side

The guiding The guiding /key/ /key/ element in the pathogenesis element in the pathogenesis of torticollis is an abnormal changes in of torticollis is an abnormal changes in clavisternomastoid muscle, that is lead to its clavisternomastoid muscle, that is lead to its fibrous degeneration. Degenerated muscle fibrous degeneration. Degenerated muscle begins to delay in growth and in some time begins to delay in growth and in some time becomes shorter than the opposite muscle. becomes shorter than the opposite muscle. Shortened muscle tension makes its points of Shortened muscle tension makes its points of attachment closer. This leads to patient's attachment closer. This leads to patient's head tilt head tilt /inclination/ /inclination/ on the affected side and on the affected side and head’s turn to the opposite side. That is the head’s turn to the opposite side. That is the way of forming of the main symptom of the way of forming of the main symptom of the disease - wrong head position, called disease - wrong head position, called torticollis. On the background of it other torticollis. On the background of it other secondary changes in skull and spine are secondary changes in skull and spine are developed. This sequence of muscular developed. This sequence of muscular torticollis development makes clear why the torticollis development makes clear why the symptoms in newborns in the first days of life symptoms in newborns in the first days of life are so poor.are so poor.

In most cases the initial symptom of the In most cases the initial symptom of the disease is the thickening and sclerotic disease is the thickening and sclerotic compaction of clavisternomastoid muscle, compaction of clavisternomastoid muscle, which appears at the end of the second week. which appears at the end of the second week. It is located in the middle or lower third of the It is located in the middle or lower third of the muscle and muscle and hhas fusiform shape. In opinion of as fusiform shape. In opinion of most authors it is a place where tendon most authors it is a place where tendon degeneration is observed. As a rule, at the degeneration is observed. As a rule, at the end of the 2nd month of life the limit in end of the 2nd month of life the limit in turning head to the affected side and its turning head to the affected side and its inclination to the opposite one is clearly inclination to the opposite one is clearly visible. At the same time secondary visible. At the same time secondary deformitiesdeformities – – asymmetry of the skull and face, asymmetry of the skull and face, which can be detected by different form and which can be detected by different form and size of auricles at this age – size of auricles at this age – begin to be begin to be identified. identified.

The forced head position causes the The forced head position causes the noticeable asymmetry of facial skeleton by 3-noticeable asymmetry of facial skeleton by 3-6 years old. All the skull bones, especially the 6 years old. All the skull bones, especially the lower jaw, are involved into the deformation lower jaw, are involved into the deformation process, forming the so-called "scoliosis of process, forming the so-called "scoliosis of face". The vertical size of face decreases and face". The vertical size of face decreases and the horizontal one increases on the side of the horizontal one increases on the side of lesion. All the lines, which connect bigeminal lesion. All the lines, which connect bigeminal points of face, cross in the space on the points of face, cross in the space on the affected side; affected side; while while nose, mouth, chin are nose, mouth, chin are situated on the concave to the affected side situated on the concave to the affected side curve /Felcker’s symptomcurve /Felcker’s symptom//. In addition, there . In addition, there is a compensation of bent head position in is a compensation of bent head position in congenital muscular torticollis by raising the congenital muscular torticollis by raising the girdle of superior extremities and lateral head girdle of superior extremities and lateral head displacement towards shortened muscle. displacement towards shortened muscle. Radiography detects asymmetry of the skull, Radiography detects asymmetry of the skull, which can be measured by a special technique which can be measured by a special technique and is a sign of severe forms of disease.and is a sign of severe forms of disease.

Treatment of congenital muscular torticollis is Treatment of congenital muscular torticollis is conducted by conservative and operative conducted by conservative and operative methods. Patients in the age of 1 year are methods. Patients in the age of 1 year are treated conservatively. Effectiveness of treated conservatively. Effectiveness of conservative treatment depends on early conservative treatment depends on early diagnosis diagnosis /it’s better on /it’s better on the second week of the second week of illnessillness//..The panel of procedure involves corrective The panel of procedure involves corrective laying, therapeutic exercises and laying, therapeutic exercises and physiotherapy. The child lay on the unaffected physiotherapy. The child lay on the unaffected side to the wall, so that he could turn his side to the wall, so that he could turn his head to the affected side when various stimuli head to the affected side when various stimuli appear.appear.

Up to 3 months passive exercises are Up to 3 months passive exercises are performed - turnings the head to the affected performed - turnings the head to the affected side and its inclination towards unaffected side and its inclination towards unaffected side. They perform about 20-30 turnings and side. They perform about 20-30 turnings and inclinations before each feeding. The inclinations before each feeding. The corrective position is ensured by cotton-gauze corrective position is ensured by cotton-gauze pad pad /pillow//pillow/. Massage prescribed to the . Massage prescribed to the patients should relax the muscles on the patients should relax the muscles on the affected side and reinforce the muscle tonus affected side and reinforce the muscle tonus on the opposite side. Physical therapy on the opposite side. Physical therapy techniques include heating procedures - techniques include heating procedures - solux, paraffin and electrophoresis with solux, paraffin and electrophoresis with potassium iodide, lidazapotassium iodide, lidaza

Surgical treatment includes removing of the Surgical treatment includes removing of the main link of the disease - shortened main link of the disease - shortened clavisternomastoid muscle. The optimal age clavisternomastoid muscle. The optimal age for surgery is 1-3 years. The most effective for surgery is 1-3 years. The most effective operation was offered by Zatsepin. It involves operation was offered by Zatsepin. It involves dissection of sternal and clavicular cruses of dissection of sternal and clavicular cruses of the muscle with the obligatory dissection of the muscle with the obligatory dissection of the surface layer of neck fascia in a lateral the surface layer of neck fascia in a lateral triangle. Thanks to this, the edges of the triangle. Thanks to this, the edges of the dissected muscle dihescence, forming a dissected muscle dihescence, forming a diastasis that reliably prevents the possibility diastasis that reliably prevents the possibility of relapse of disease. To increase the of relapse of disease. To increase the diastasis the resection of the lower areas odiastasis the resection of the lower areas of f clavisternomastoid muscle by Mikulic within clavisternomastoid muscle by Mikulic within 2-3 cm is also performed. 2-3 cm is also performed.

Operation by Zatsepin (a), fixOperation by Zatsepin (a), fixation of ation of head with the help of plaster bandage (head with the help of plaster bandage (бб) ) and headholder (and headholder (вв))

In order to achieve a better cosmetic effect In order to achieve a better cosmetic effect some authors recommend allongement some authors recommend allongement (lengthening) of muscle instead of its (lengthening) of muscle instead of its intersection, but this operation is not widely intersection, but this operation is not widely used because of the high likelihood of used because of the high likelihood of relapse.relapse.In the postoperative period the patient is In the postoperative period the patient is Glisson’s skull traction tongs in order to hold Glisson’s skull traction tongs in order to hold the head in hypercorrection position. After 6-the head in hypercorrection position. After 6-7 days a plaster collar is set for 30 days.7 days a plaster collar is set for 30 days.After the After the finishingfinishing of immobilization of immobilization therapeutic exercises, massage, therapeutic exercises, massage, physiotherapy are conducted within 3-6 physiotherapy are conducted within 3-6 weeks.weeks.In a case of perfectly performed operation In a case of perfectly performed operation and proper management of patients the and proper management of patients the recovery is obvious in the postoperative recovery is obvious in the postoperative period.period.Untreated cases lead to severe irreparable Untreated cases lead to severe irreparable deformations.deformations.