BY SUNNDEEP CHOPRA:
Introduction: Scoliosis has been most commonly defined or explained as the lateral (away from the body) curvature or bending of the spine in the upright or straight position. The lateral curvature is most commonly accompanied by or then tangential to the onset or setting in of some rotational or movement related deformity. Man is the only homo sapien who boasts of an erect structure and is hence most affected by this condition.
Nature has been kind enough to design or devise four distinct or different physiological curves within the expanse of the so-called erect spine; cervical and lumbar lordosis, dorsal curve in the thoracic spine and the sacral region. Thus, the gradual development of a curvature of the spine is a deviation from the set/established norm and hence throws the optimally adjusted routine of the spinal mechanism haywire; thereby leading to or posing the below mentioned problems or complications:
Ø A cosmetically unacceptable deformity that does irrepairable damage to the self esteem of a victim.
Ø Deranges or rearranges the load bearing and force or pressure exerting/transmitting mechanism characteristic of the spine.
Ø Jeopardizes or then seriously affects the optimal functioning of vital and life sustaining organs like the lungs and heart by congesting and overcrowding the rib cage/ribs.
Ø Managing or then treating the condition is often an utterly thankless and harrowing experience for the physician/specialist.
TREATMENT: The early detection or spotting of the curve is a pre-requisite of all scoliosis related treatments. A curve which is conspicuous or easily detectable in the standing or erect position is indicates the fact that the resultant curvature has already reached the 30-40 degree level. The detection of the curve before it hits or reaches the 20 degree level is imperative as most curves over and above the 20 degree mark show a marked proclivity towards further progression and the increasing curvature cannot be arrested in majority of cases.
Repeated, timely and periodic assessment/re-assessments are most crucial and all ensuing treatments are with subject to the age of the patient and the severity or seriousness of the rate of bending of the spine. The ensuing treatment is entirely dependent upon the biological age of the patient and severity/seriousness of the curvature.
NON SURGICAL TREATMENT: A clinical or dispassionate observation is the only/primary mode of treatment in vogue at present in all cases below the 20 degree mark. Radiography or x-rays are the only definitive documentation or record of the size of the curve and it’s gradual progression.
Generally Accepted or Followed Guidelines:
Ø Curves below the 20 degree mark are examined on a bi-annual basis in the case of skeletally immature patients (persons with inadequate bone density and development with relation to his biological age.)
Ø Curves yet to hit the magical 20 degree mark require no further evaluation/related study/observation in the case of skeletally mature persons/patients.
Ø Curves exceeding 20 degrees should be examined on a quarterly basis in the case of skeletally immature persons and orthotic (spine/bone related) treatment methods should be immediately initiated in all cases exceeding the 25 degree mark.
Ø Curves exceeding the 30 and even 40 degree mark oftentimes do not require any doctoral treatment or surgical intervention. But the same are subjected to a radiological examination once in every two to three years to record and document further signs of progression.
SURGICAL TREATMENT: Is indicated/highly desirable/oftentimes the only course of treatment if a high degree throracic curve with the inherent potential to cause subsidiary damage (secondary changes) to the ribs and rib cage. Enclosing the affected area with the aid of a cast has proved to be singularly ineffective in such cases. Spinal surgery is indicated or then resorted to most often when the curvature exceeds/begins to exceed the 60 degree mark and the same is aimed at obtaining or achieving the correction of the curve and precluding any further incidents of curvature.
EXERCISES:
1. Deep breathing exercises are both highly recommended and of immense benefit.
2. Balancing exercises, i.e. asking the patient to walk around with a measured gait while placing either a book or then any other weight on his head.
3. Active restoration of movement exercises of the spine/spinal area.
4. Exercises aimed at strengthening both the abdominal wall as well as the spinal area.
5. Passive or dormant stretching of the supporting/allied muscles on both sides of the curvature is both highly effective as well as deeply desirable.
The patient must simultaneously be educated or then enlightened about the resultant benefits of maintaining an erect posture and frequent medical check-ups/follow ups in order to keep a record of and measure the progression of the curvature of the spine if any. The benefits/advantages attached to the embracing of/adoption of a strategic exercise programme also need to be impressed upon the patient.
CLINICAL FEATURES OR SYMPTOMS: Though idiopathic scoliosis (curvature of the spine that can occur in children between the age of 10 and the age of attaining maturity, the resultant curvature could either be towards the left or right) can occur at any age, it is most commonly observed or manifested between the ages of 10 and 13 (about three percent of all children are affected and the periodic screening of all children on either an annual or then bi-annual basis should be mandatorily followed by all schools to rule out the incidence of this condition in children of that age), the rate of incidence is much higher in females in comparison to males. The disease/condition is always asymptomatic (without any distinguishing features) and is more often than not discovered accidentally while some other clinical investigation is in progress. The diagnosis/recognition of the disease is usually made during the course of a routine or normal physical examination.
The patient should always divest himself of all clothing till the waist or then desist from wearing any clothes up to the waist level (prudes may don a swimsuit if they so desire) and a pre-determined routine should be scrupulously followed. The shoulders and iliac crest (area between the shoulder blades) should be minutely examined to rule out any and every possibility of their not being at the same level. The scapulae, rib cage and flanks should be subsequently examined to preclude/rule out any signs of asymmetry. The spinous processes should be palpated (felt with the hands of a medical practitioner) in order to determine their alignment or lack of it. The appearance of any protrusion or clearly visible extrusion in the spinal area indicates or points towards the presence of a condition commonly referred to as spinal rotation. The concerned patient is asked to bend forward in order to ascertain as well as rule out this possibility.
ORTHOTIC TREATMENT OR THEN USAGE OF BRACES, SLINGS AND SO ON: The same has proved to be highly effective/of immense benefit in the treatment of sekeletally immature persons. The ‘Milwaukee Brace’, Boston Brace, Reisser’s turn buckle cast, localizer cast and so on are commonly used and the 20 degree level or mark is still the gospel as far as bracing goes. Exercises and electrical stimulation have proved to be of little or no benefit whatsoever in the case of adolescent patients of the disease.
Orthotic treatment through/with the help of either a Milwaukee or Boston Brace is highly recommended and resorted to in cases of patients with structural coliosis (curves below the 40 degree mark) as mere exercises and allied movements prove to be totally ineffective in both managing as well as improving the plight of the patient. However active exercises within the brace or confined area help or then essay a crucial role in preventing further deterioration or worsening as well as maintaining the degree of correction or redemption achieved.
Note:
Ø The brace should be worn throughout a 24 hour period (course of the day)
Ø The size and height, length of the brace needs to be continually adjusted especially in the case of growing children.
Ø The brace needs to be continually worn till the minor/patient achieves a state of skeletal maturity and the patient should be gradually weaned away from his dependence on the same.
Ø Exercises should be initiated/repeated within the confines of the brace and the exercises should be repeated in 10 minute intervals while holding each of them for a minimum period of 5 seconds each.
IDIOPATHIC SCOLIOSIS (causes unknown): This is the most common and widespread form of the disease and accounts for a little over 75-90% of all recorded/manifested cases, the same seems or then appears to be a hereditary disorder but the reasons behind/causes for it’s extremely high rate of incidence remains obscure. Clinicians have further subdivided the same into three varieties or categories for convenient diagnosis of the disease. The three common varieties are:
Infantile:
- Accounts for between 70-90% of all recorded cases.
- Most commonly observed in children below 3 years of age.
- The curve is either progressing or regressing.
Treatment:
+ observation is the most common mode of treatment in all cases below the age of 3 years.
+ bracing or then taking recourse to the employment of a brace is highly recommended in all cases where the curve has exceeded the 20 degree mark.
+ surgical fusion or then artificial conjunction between two different structures/ bones is the only treatment mechanism in the most severe cases of the disease.
Juvenile:
# accounts for approximately 15% of all recorded cases.
# rate of occurrence is most commonly the age span between 4-10 years of age.
# characterized or distinguished by the presence of an idiopathic curve that is most commonly inclined to the right.
Treatment:
Ø Observance is the most common mode of treatment in cases where the curve is yet to exceed the 20 degree mark.
Ø The Milwaukee Brace is the chosen mode/form of treatment in case where the curve has crossed the 20 degree limit.
Ø Surgical correction and fusion is resorted to as soon as the spine shows a curvature of more than 60 degrees.
Adolescent:
· Accounts for 2-3% of all recorded cases
· The age of onset or manifestation is normally between the 10-16 age bracket.
· The female to male ratio is normally in the 3:6:1 ratio.
Treatment:
· Surgical intervention or correction is the only mode of treatment.
Scoliosis has been further sub divided into two further categories for ease of diagnosis and treatment:
a. Congenital Scoliosis: This is caused by or then on account of a defect in segmentation or division and the same is most commonly caused by a lateral bar or upper limit or then on account of a defect in the formation of which the hemivertebrae or double vertebrae are an integral part. These curves progress or continue at breakneck speed and surgical fusion of both the convex and concave sides of the curve is the only method or form of treatment in almost all cases.
b. Paralytic Scoliosis: This is caused by or then a result of muscular (muscle) imbalances on either side of the trunk. The most common or widespread cause for the same is either anterior or rear poliomyletis, cerebral palsy (ies), muscular dystrophies and so on.
VARIETIES OR TYPES OF SCOLIOSIS:
A. Structural Scoliosis: The curves are rigid, fixed and non flexible in all cases of structural coliosis and the same fail to correct themselves with the adoption of side bending measures. The lateral or forward and backward bending of the spine is anything but smooth sailing or totally asymmetric and the involved vertebrae are either stuck or fixed or thn in a rotated position or both.
B. Non Structural Coliosis: The curves are flexible, malleable and self correcting in the case of non structural coliosis. The same is seen as a corollary to or then compensatory mechanism for a discrepancy or defect in the length of a patient’s leg, fixed flexion deformity of the hip (compensatory scoliosis), allied or interlinked diseases and last but not the least on account of poor postural habits or lank body structure (postural scoliosis).
IMPORTANCE OF THE ARM SPAN: The arm span in a normal child is roughly equivalent to his body height (or height from head to heel) within an error span of 1 cm. The measurement of arm span help in assessing the actual height of the child as if scoliosis was conspicuous by it’s absence in the case of a scoliotic child. Radiographic evaluation is the only available determinant or tool capable of assessing the severity or seriousness of each case and is hence resorted to periodically in order to determine the degrees of progression of the curve or otherwise.
SCOLIOTIC FACTS OR QUICK FACTS:
Ø A structural curve is a laterally curved spine lacking in or deficient in normal flexibility.
Ø The earliest curve to make an appearance is christened as ‘the primary curve’.
Ø The curve that begins to manifest or announce itself just above or below the primary curve in order to counterbalance the spice is deemed to be a secondary curve.
Ø The largest structural curve in the human body in terms of dimensions has the dubious distinction of being the major curve.
Ø The smallest or minutest curve is conversely christened as the minor curve.
Ø The most significantly deviated or then vertebra tilting farthest away from it’s vertical axis is termed as the Apical Vetrebra.
Radiological parameters in scoliosis
· Cobb’s Angle: is indicative of or then means of measuring the severity of the curve.
· Nash and Moe: indicator of the severity or then lack of vertebral rotation.
· Rib Angle of Mehta: indicates or highlights curve progression
· Reisser’s Sign: points towards or indicates the spinal maturity and the period of cessation of the scoliotic curve.
Always remember four o’s in scoliotic treatment:
· Observation for curves less than 20 degrees.
· Orthosis for curves varying between 20 and 40 degrees.
· Operation for curves exceeding 40 degrees.
· Other allied measures like exercises, electrical stimulation and so on.
Scoliosis versus traction:
Ø Intermittent or periodic traction is most effective.
Ø Cotrel traction is twice as effective or efficacious as intermittent traction.
Ø Gravitational traction is twice as efficacious as cotrel traction and helps or aids the patient in stretching the spine and relaxing the contracted soft tissues.
Other or additional measures prior to surgery for scoliosis;
Ø Detailed and exhaustive neurological examinations and charting of muscle growth or then the lack of it.
Ø Postural or body structure related corrections
Ø Chest physiotherapy to increase the inhalation/breathing capacity of the patient.
Ø Precise measurement of the rib hump.
Ø Gait analysis and isometrics to glutei and isotonics to the knees and ankles.
Ø Various/multifarious traction options.
ADDITIONAL FACTS:
· Scoliosis is nothing but the lateral curvature of the spine.
· The idiopathic variety accounts for almost 90% of all cases.
· The rate of incidence is higher in the female species.
· The humble and stereotyped x-ray is the only definite means of documenting and recording the curve size and it’s subsequent progression.
· The most significant component or then aspect of the onset of required treatment is early or timely detection.
· Curves less than 20 degrees entail hawk like observation.
· Curves exceeding 20 degrees require necessary treatment.
· Curves varying between 20 and 40 degrees can be most commonly addressed with the help of the Milwaukee brace and the same has to be worn for at least 23 hours a day for a minimum prescribed period of 2 years.
· Curves that have exceeded the 40 degree mark require or then can only be treated through surgical intervention and fusion.
Facts about curve progression:
Ø Curves not exceeding 20 degrees will show remarkable and spontaneous signs of improvement in almost half or 50% of all cases.
Ø No accurate or precise method to predict the outcome of curves has been evolved as yet.
Ø At least 20% of all curves exceeding the 30 degree mark will show signs of progression/deterioration.
Ø Progression is far more prevalent amongst young children.
Ø The chances/percentages of curve progression are inextricably linked with/to the size or dimensions of the curve.
Ø Curves in females and double curves show a much greater proclivity towards onward progression.
OTHER/ALTERNATIVE FORMS OF TREATMENT:
Physiotherapy Management in Scoliosis: Physiotherapy management in scoliosis is both indicated/highly recommended in cases of patients with curves lesser than 40 degrees. These curves are closely linked with/to postural scoliosis and are managed by taking recourse to the below mentioned measures:
Ø Screening Methods: patients are asked/requested to subject themselves to periodic screening or measuring methods.
Ø Posture Correction: Added or special emphasis is laid on traction of 2 he adoption of or then initiation of the requisite remedial measures in order to address the problems related to faulty posture and the patient is guided towards course/postural corrections with the help of both active as well as passive measures.
Ø Active methods could include the position of the leg and trunk levels through a trial and error method upon the identification of the levels at which the curves get corrected and identified. The concerned patient is asked to duly make note of these indicators and correctional or remedial measures are initiated in order to achieve the correction.
Passive Methods:
· Unequal Traction: The commonplace way of going about the same is to instruct/guide the patient in hanging from a suspension with the aid of only one hand.
· Unequal traction can also be initiated with the aid of a traction apparatus and the ensuing results more often than not exceed the most optimistic estimates.
· The patient is given traction along the length and direction of one leg and pelvis by one physiotherapist, while counter traction is provided along the chin and occiput lines by a second therapist as a counter measure or counterpoid. The synonymous application of these two forms of traction when the patient is lying down in a supine position helps in course and posture correction and is christened as Axial traction in medical parlance.
· Proper, necessary and much required education is imparted or then passed onto the patient in an effort towards making him realize the underlying benefits of holding/continuing with the course correction till the desired results are obtained in due course of time.
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