DEFORMITIES OF THE SPINE Flashcards
DEFORMITIES OF THE SPINE
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Anatomy of the spine
The vertebral column is composed of 33 vertebrae, including 7 cervical, 12 thoracic, 5 lumbar, 5 inferiorly fused vertebrae that form the sacrum, and 5 coccygeal. The spinal column not only bears the weight of the body, but it also allows motion between body parts and serves to protect the spinal cord from injury. Before birth, there is a single C-shaped concave curve anteriorly. At birth, infants have only a small angle at the lumbosacral junction. As a child learns to stand and walk, lordotic curves develop in the cervical and lumbar region (age 2 years). These changes can be attributed to the increase in weight bearing and differences in the depth of the anterior and posterior regions of the vertebrae and disks
SCOLIOSIS
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Definition
Scoliosis is an abnormal lateral curvature of the spine. The curvature may be toward the right (more common in thoracic curves) or the left (more common in lumbar curves). Rotation of the vertebral column around its axis occurs and causes the associated rib cage deformity. Scoliosis is often associated with kyphosis and lordosis.
Functional (postural) scoliosis- may be caused by factors other than vertebral involvement, such as pain, poor posture, leg length discrepancy, or muscle spasm induced by a herniated disk or spondylolisthesis. These curves disappear when the cause is remedied. Functional scoliosis can become structural if untreated.
Structural scoliosis – Is a fixed curvature of the spine associated with vertebral rotation and asymmetry of the ligamentous supporting structures. It can be caused by deformity of the vertebral bodies and may be congenital (e.g., wedge vertebrae, fused ribs or vertebrae, hemivertebrae), musculoskeletal (e.g., osteoporosis, spinal tuberculosis, rheumatoid arthritis), neuromuscular (e.g.,cerebral palsy, polio, myelomeningocele, muscular dystrophy),or, most commonly, idiopathic.
Etiology
Scoliosis is classified as: Structural or Functional
Structural scoliosis x Idiopathic (unknown cause; 80%of all cases) x Osteopathic (as a result of spinal disease or bony abnormality), x Myopathic (as a result of muscle weakness), x Neuropathic (as a result of a central nervous system [CNS] disorder).
Non –structural scoliosis
x poor posture
x leg length discrepancy
x muscle spasms due to herniated disk or spondylolisthesis
Epidemiology
Onset or incidence of scoliosis
x Infantile (0 to 3 years), juvenile (ages 3 to 10), adolescent (age 10 until bone maturity at between 18 and 20 years of age), or adult (after skeletal maturation).
x Progressive idiopathic scoliosis are found in the adolescent age group when the growth velocity of the spine again increases after relatively slow growth period between the ages of 5 and 11 for girls (13 for boys).
x Infantile idiopathic scoliosis (is characterized by curvatures that are most often thoracic and toward the left and most commonly affects males.
x Juvenile idiopathic scoliosis is characterized most often by a right thoracic curvature and can be rapidly progressive.
x Adolescent idiopathic scoliosis of greater than 30 degrees is seen most often in females without any neurologic. Scoliosis affects boys and girls equally, but girls are more likely to develop more severe curvatures requiring intervention.
x Adult scoliosis (curves greater than 30 degrees)
x The prevalence of idiopathic scoliosis is reported to be between 0.3% and 2% of the population.
x The incidence of degenerative scoliosis is reported as 6% in people over 50 years of age and
36% in persons over 50 with osteoporosis
Clinical manifestation
x Curvatures of less than 20 degrees (mild scoliosis) rarely cause significant problems. Severe untreated scoliosis (curvatures greater than 60 degrees) may produce pulmo- nary insufficiency and reduced lung capacity, back pain, degenerative spinal arthritis, disk disease, vertebral sub- luxation, or sciatica.
x Common characteristics of scoliosis are asymmetric shoulder and pelvic position, often identified when clothes do not hang evenly. Curves are designated as right or left depending on the convexity (e.g., right thoracic scoliosis describes a curve in the thoracic spine with convexity to the right).
x The adult with scoliosis often presents with back pain that is considered multifactorial, arising from muscle fatigue, trunk imbalance, facet arthropathy, spinal stenosis, degenerative disk disease, and radiculopathy.
x Paraspinal muscles become asymmetric as the muscles on the convex side of the curve become rounded, appearing prominent or bulging, while the muscles on the concave side flatten. Rotational deformity on the convex side is observed as a rib hump (gibbus) sometimes seen in the upright position but always apparent in the forward bend position.
Pathophysiology
Non-Structural scoliosis- is a temporary curve that changes, and is caused by an underlying condition such as difference in leg length, muscle spasm, or inflammatory conditions such as appendicitis.
Structural scoliosis- this is the result of disease, such as the inherited tissue disorder known as marfan‘s syndrome. Other causes include neuromuscular disease (such as cerebral palsy, poliomyelitis or muscle dystrophy), birth defects, injury, infection, tumors, metabolic diseases, rheumatic diseases, or unknown factors.
Diagnosis
Diagnosis by clinical examination requires the client to bend forward 90 degrees (Adams forward bend test) with the hands joined in the midline as if taking a dive into a swimming pool. A scoliometer also can be used to measure the angle of trunk rotation. Scoliosis is usually confirmed with an x-ray, spinal radiograph, CT scan, MRI or bone scan of the spine. The curve is then measured by the Cobb Method and is discussed in terms of degrees.
An abnormal finding includes asymmetry of the height of the ribs or paravertebral muscles on one side. The examiner also checks for leg length discrepancy and other asymmetries and for the presence of hair patches, nevi, pits, or areas of abnormal skin pigmentation in the midline indicating possible underlying spinal abnormality.
Differential diagnosis
x Congenital scoliosis x Spina bifida x Arnold-Chiari malformation (tethered spinal cord) x Leg-length discrepancy x Neuromuscular scoilisis
Prognosis
Postural curvatures resolve as the primary problem is treated. Structural curvatures are not eliminated but rather increase during periods of rapid skeletal growth. If the curvature is less than 40 degrees at skeletal maturity, the risk of progression is small. In curvatures greater than 50 degrees, the spine is biomechanically unstable, and the curvature will likely continue to progress at a rate of 1 degree a year throughout life.
Complications
x Lung and heart damage. In severe scoliosis, the rib cage may press against the lungs and heart, making it more difficult to breath and harder for the heart to pump.
x Back problems. Adults who had scoliosis, as children are more likely to have chronic back pain than are people in the general population.
Treatment
x Prevention of postural or idiopathic structural scoliosis is the key to management of the majority of scoliosis cases.
x Early detection allows for early treatment without surgical intervention and with good long- term results.
x Overall goals of management are to prevent severe and progressive deformities that might lead to decreased cardiorespiratory function.
x Progressive resistive exercises specifically aimed at the trunk rotators and extensors are effective for curves less than 45 degrees
x Adults with scoliosis should follow a conservative non-operative course of physical therapy to improve aerobic capacity, strengthen muscles, and improve flexibility and joint motion; nonnarcotic analgesics; nutritional counseling; smoking (or tobacco use) cessation; and nerve root blocks, facet injections, and epidural steroid injections before surgery is considered.
x Surgical intervention (e.g., fusion with posterior segmental spinal instrumentation) may be necessary for curvatures greater than 45 degrees, in the presence of chronic pain, or when the curvature appears to be causing neurologic changes.
