Affections of the Spine and Thorax

Affections of the spine

SCOLIOSIS
Scoliosis

is a lateral curvature of the spine. It is a deformity rather than a disease.

Nonstructural Scoliosis
One

large group of scoliosis patients is made up of those whose spinal curvatures is the result of temporary postural influences.

 It

is not accompanied by rotational or asymmetric changes in the individual structures of spine. The curve is not fixed; the patient can actively and completely correct the deformity by sitting erect.

 It

may result from poor posture or leg length discrepancies and usually poses no major therapeutic problem. A non-structural scoliosis may also be caused by nerve root irritation such as the sciatic scoliosis seen in acute lumbar disk herniation.

Structural Scoliosis
Is

characterized by definite morphologic abnormalities, therapeutic effort is most concerned.

Congenital Scoliosis is caused by a

defect in embryologic development of the vertebrae or ribs, such as hemivertebra.

Neuromuscular Scoliosis is

associated with a great variety of paralytic disorder that causes asymmetric paralysis of the trunk muscles.

 It

occurs also in neurofibromatosis; in skeletal diseases such as osteogenesis imperfecta, Marfans syndrome, and osteomalacia; especially conditions such as unilateral thoracic conditions such as thoracoplasty and chronic empyema.

 Pathogenesis

is unknown. Such cases are classified as idiopathic scoliosis.

Pathology
All

the structure of the concave side are compressed or shortened, whereas those in the convex side may remain normal of become lengthened.

 The

apical vertebra, situated at the middle of the curve, shows the greatest change.

 The

intervertebral disks are compressed on the side of the concavity and may bulge on opposite side as a result of the pressure; the nucleus pulposus migrates toward the convex side.

 The

anterior longitudinal ligament is thickened on the concave side and thinned on the convex side.

 Malalignment

of the spinal joints leads to degenerative arthritic changes in later life.

 The

rotation, which is greatest in the apical vertebra, vertebral body always turns toward the convex side of the curve, spinous process toward the concavity.

 In

a posterior rotation of the chest wall, a posterior prominence of the rib cage on the convex side of the curve, and an anterior prominence of the thorax on the concave side.

 Cardiopulmonary

failure is a frequent cause of death in patients with severe scoliosis.

 Significant

changes in pulmonary function are usually not apparent in curves under 55 degrees. At 100 degrees the patient often becomes symptomatic.

Roentgenographic Picture
A

major, or primary, curve, which is usually the largest and most rigid, is generally accompanied by minor, or compensatory, curves above and below.

 The

minor curves are more flexible and show fewer structural changes. Those in the thoracic and cervical regions tend to be most rigid and deforming.

The

Cobb method of measurement is the most widely accepted technique. Anteroposterior view of the entire spine made with the patient bending as far as possible to the left and to the right gives evidence of the flexibility of major and minor curves.

lateral roentgenogram of the spine demonstrates kyphotic and lordotic curves and detects spondylolisthesis sometimes associated with scoliosis. Protective shields placed over the breasts and thyroid has been recommended by some to reduce repeated radiation exposure of these organs.

Idiopathic Scoliosis
Idiopathic

Scoliosis encountered in adolescents is the most common. It is seen predominantly in girls and is associated with a significant familial occurrence.

 Hypotheses

of etiology, including unrecognized paralysis, asymmetric growth of vertebral epiphyseal plates, and minor disorders of proprioception and balance associated with labyrinthine disorders.

 An

Scoliosis, uncommon to US, affects boys more frequently than girls and resolves spontaneously in most instances.

infantile type of Idiopathic

distribution and beginning between 3 years of age and the onset of puberty.

juvenile variety, of equal sex

Clinical Picture
As

a rule there is no complaint until the deformity of the back is noticed.very gradual development. The patient may be brought to the physician because of a high shoulder, a prominent hip, or a projecting shoulder blade.

 Occasionally

the child may complain of fatigue and backache before a deformity is noted. There may be shortness of breath from diminished respiratory capacity and gastrointestinal disturbances from crowding of the abdominal organs.

 Viewed

from the back, the most prominent features are the spinal curvature, asymmetric flank folds in the presence of a level pelvis, and prominence of the scapula and shoulder on the convex side of the curve.

 In

adolescent idiopathic scoliosis the thoracic curve is usually convex to the right and the lumbar curve to the left.

 In

the lumbar area, spinal rotation results in prominence of the paravertebral muscles on the convex side, while in the thoracic region rotation of the rib cage elevates the scapula and shoulder.

plumbline dropped from the spinous process of C7 should pass through the intergluteal crease. If the line falls to one side of the crease, the scoliosis is uncompensated.

Diagnosis
Idiopathic

scoliosis is diagnosed be exclusion. The neurologic findings should be normal, limb lengths equal, and manifestations of congenital disorders or systematic disease absent.

Prognosis
Among

the large majority of adolescent children in whom structural scoliosis is detected in routine school screening programs, significant progression of the spinal curve does not occur.

 If

the curve is greater than 20 to 30 degrees and the child still has several years to grow when deformity is first detected, the chances of progression are increased. Thoracic and double primary curves are more likely to progress than are lower curves.

 Curves

greater than 40 degrees at maturity, however, may continue to progress in adult life, although usually at a slower rate.

Treatment
Many

persons with idiopathic scoliosis will not require definitive treatment. Cosmetic considerations often influence the decision.

 Thoracic

curves that exceed 35 degrees are cosmetically unacceptable. The basic aims to recognize curvature early, to evaluate its chance of progressing accurately, and insofar as possible to correct it and maintain its correction.

Nonsurgical Measures
Two

types of nonsurgical treatment; First consists of exercises and observation. This treatment is reserved for mild cases with flexible curves less than 20 degrees or perhaps a little more if the patient is near maturity.

 Exercises

have not been shown to exert any lasting corrective influence on a structural curve, but they may serve to maintain spinal flexibility. If there should be any sign of progression, more aggressive treatment is indicated.

 The

second nonsurgical treatment is the use of braces. Most effective use is the Milwaukee, or Blount, brace. It incorporates both active distractions, encouraged by adjustable uprights extending from head to pelvis, and adjustable posterolateral pressure over the thoracic prominence.

 The

brace is worn for 23 hours a day and removed for 1 hour for bathing, skin care, and additional exercises.

 Early

progressive but flexible curves of young children of 20 to 40 degrees, the Milwaukee brace can be used to correct and maintain correction of the deformity. It is not effective in curves of over 40 to 50 degrees.

 The

brace must be worn until all tendencies toward increase of the curvature have ceased. Bracing must usually be continued until skeletal maturity, demonstrated by closure of the vertebral and iliac apophyses. In the final months the brace is worn only at night

 Since

possible complications of wearing the brace include skin allergies, pressure sores, and emotional disturbances, the patient should be seen at frequent intervals.

 The

shorter braces are most effective in the treatment of flexible lower curves of less than 40 degrees

Surgical Measures
Surgical

treatment is indicated when curvatures of unacceptable degree cannot be satisfactorily improved or their improvement satisfactorily maintained by nonsurgical measures.

 Progressive

curves of more than 45 degrees on children who are still growing are best treated surgically. Only about 5% of the cases of idiopathic scoliosis are severe enough to require spinal fusion.

 Spinal

arthrodesis is the most effective means of permanently maintaining correction of the curvature.

 The

surgical correction of severe curvature may be facilitated by Inserting the metal distraction rods devised by Harrington; in addition to these devices, however, spinal fusion necessary

 Spinal

fusion for scoliosis must be followed by a period of immobilization in a plaster cast or brace for 6 to 9 months

Congenital Scoliosis
Congenital

scoliosis is caused by abnormalities in the development of the vertebrae. Embryonic anomalies result from failure of portions of the vertebrae to form (hemivertebra), from failure of segmentation (seperation) of the vertebrae, or from a combination of these factors.

 Two

or more vertebral bodies united in a single mass of bone called block vertebrae. The spinal curves of congenital scoliosis tend to be more rigid than those of other forms of scoliosis.

 Congenital

scoliosis is often associated with other congenital anomalies. These include spina bifida occulta, diastematomyelia, congenital heart defects, and anomalies of the genitourinary tract.

Treatment
It

must begin much earlier and must continue for a much longer period. It is important to institute treatment early and not to permit the deformity to progress.

 When

spinal growth is completely tethered on one side, as by a unilateral bar, continued unilateral growth can result only in progress deformity. Posterior spinal fusion is indicated at a very early age in these patients.

When severe deformity is present, limited correction can be gained by means of traction methods such as halofemoral traction. Harrington instrumentation is probably best avoided in operations for congenital scoliosis, since any sudden correction of the deformity may injure the spinal cord.

Neuromuscular Scoliosis (Paralytic Scoliosis)

Neuromuscular

Scoliosis is the result of asymmetric paralysis of muscles that stabilize the spine.

 It

may develop in a great variety of neurologic disorders and can progress to severe collapse of the spinal column, impairing the patients respiratory function and ability to sit and stand.

 It

is encountered most frequently in stable or slowly progressive neuromuscular affections. Paralytic scoliosis is common in patients with Friedreichs ataxia, severe myelomeningocele, and Charcot-Marie-Tooth Disease.

 Every

early paralytic spinal curve is likely to progress. In paralytic scoliosis the prognosis is determined by the primary neurologic disorder.

Treatment
In

patients with partial paralysis of the muscles of respiration, pressure on the thorax by a cast or brace is poorly tolerated. Where skin is anesthetic, braces may cause pressure necrosis.

 When

the deformity is progressing or when sitting ability or respiratory function is deteriorating, surgical treatment of neuromuscular scoliosis is usually indicated.

 Preliminary

improvement of severe curves may be accomplished by halo-femoral traction. Harrington instrumentation is extremely helpful in paralytic scoliosis.

 Spine

stabilization by segmental wiring of each lamina to the heavier Luque rods has been effective in paralytic scoliosis. Occasionally, in very severe curves, posterior spinal fusion should be supplemented by anterior fusion of the vertebral bodies as described by Dwyer.

 Frequently

patients require tracheostomy and respiratory support during the operation and the immediate post-operative period.

Kyphosis
Anteroposterior

curvature of the spine in which the convexity is directed posteriorly. Posterior convexity of an abnormal degree from pathologic changes located primarily in the vertebral bodies, the intervertebral disks, or the supporting musculature.

 Kyphotic

deformity occurs not uncommonly in children and young adults. The most frequent cause is faulty posture. Severe kyphosis may develop in the lumbar or lumbodorsal region of patients with myelomeningocele.

 Kyphotic

deformity seen in middle or late age groups has been called adult round back. Its causes include postural influences and common bone and joint diseases, as well as degenerative spinal lesions peculiar to adult years.

 Any

condition causing anterior wedging or collapse of the vertebral bodies may result in kyphosis. The most common of these are osteoporosis of any form, metastatic cancer, trauma, and infection.

Adolescent Kyphosis (Scheuermanns Disease, Juvenile Kyphosis, Vertebral Epiphysitis)

The

term adolescent kyphosis has been applied to a chronic affection of the vertebral bodies evidenced clinically by the gradual development of a fixed kyphosis, with which back pain may or may not be associated. The onset usually takes place in the early teens.

 The

process always involves three or more contiguous vertebrae and usually is most advanced in the lower or middle portion of the dorsal spine. It is seen with about equal frequency in boys and girls.

Etiology
Scheuermann

believed the cause to be a growth disturbance of what he termed the vertebral epiphyses. Frequent finding of irregular thinness in the vertebral end plates and protrusion of the nucleus pulposus into the vertebral bodies in this condition.

 The

cause is congenital deficiency in the thickness of the vertebral plates and that partial loss of disk substance causes excessive pressure on the anterior portion of the vertebral epiphyses.

Roentgenographic Picture
Bone

edges above and below the intervertebral spaces are ill defined and of uneven density. The vertebral end plates are irregular in outline.

 As

healing takes place, the fragmentation disappears, and the bone outlines become relatively more distinct but remain irregular. The most outstanding Roentgenographic feature is anterior wedging of the vertebral bodies as seen in the lateral view. Most normal children such clefts disappear before the tenth year of age.

Clinical Picture
The

symptoms usually begin the ages of 12 and 16 years. The first subjective evidence may be fatigue and pain in the back.

 Undue

prominence of the spinous processes of the vertebrae may be noticed, especially at the lower dorsal and upper lumbar levels, and a gradual increase in kyphosis takes place. Compensatory increase of lumbar lordosis is a frequent finding, and hamstring tightness is often associated.

 Stiffness

and tenderness may be present throughout the spine. A mild degree of scoliosis is often associated with adolescent kyphosis. In later years osteoarthritic changes and backache may develop.

Diagnosis
Adolescent

kyphosis is to be distinguished from tuberculosis and other inflammatory or neoplastic conditions that cause vertebral collapse. It is usually associated with more pain and muscle spasm, with bone destruction and with systemic symptoms not found in Scheuermanns Disease

Treatment
In

milder cases it may be advisable to have the patient limit activities that put stresses on the spine, use a fracture board without pillow, and carry out kyphosis exercises.

 The

most effective form of treatment is the Milwaukee brace. It is usually necessary to continue brace treatment for 1 to 2 years. Persistent pain in later years is an indication for posterior spinal arthrodesis and use of Harrington compression rods.

Vertebra Plana (Eosinophilic Granuloma, Calves Disease)

Vertebra

Plana is an uncommon affection, occurring usually in the dorsal spine of children between 2 and 12 years of age and characterized by pathologic changes localized in a single vertebral body.

Roentgenographic Picture
Vertebral

body may appear fragmented or eroded. Adjacent disk spaces are normal or thickened. With healing, the affected body becomes normal in density.

Clinical Picture
Pain,

fatigue, and mils angular kyphosis are characteristics muscle spasm and tenderness may also be present

Diagnosis
Differential

diagnosis should include Eosinophilic Granuloma, tuberculosis, tumor, compression fracture and congenital anomaly. Biopsy may be advisable

Treatment
Rest

in recumbency is indicated until the diagnosis has been made and the pain has subsided.

Etiology Adult Kyphosis may be produced by faulty posture, degeneration of the intervertebral disk, atrophy and collapse of the vertebral bodies, pathologic entity such as chronic arthritis, osteitis deformans, poliomyelitis, facture, metastatic tumor, plasma cell myeloma, tuberculosis, or other disease affecting the vertebral bodies or disks.

Adult Kyphosis

 Degeneration

and thinning of the intervertebral disk sometimes take place in middle life; this process may progress to cause a single, long kyphosis with flattening of the lumbar and cervical portions and forward projection of the head.

Pathology
In

adult kyphosis caused by lesions of the intervertebral fibrocartilages, the pathologic changes that occur in the disks are characteristic. Two thin plates of hyaline cartilage separate the disk from the bones above and below

 In

30% of all adult spines, localized protrusions of nuclear material through the cartilage plates and into the spongy bone of the vertebral bodies have been found Gradual thinning or collapse of the intervertebral disks allows adjacent vertebral bodies to become approximated

 In

adult kyphosis from senile osteoporosis, the disks remain relatively normal but the spongy bone within the vertebral body become atrophic and the cortex becomes thinned

 In

the thoracic spine the vertebral bodies may become wedge shaped, lumbar region they may assume a biconcave or hourglass contour as seen in lateral roentgenograms. The osteoporosis may lead to pathologic compression fractures.

Clinical Picture
It

may or may not associate with pain, weakness of the back, and general fatigue. The aching and tiring of the back usually occur below the apex of the kyphosis.

Diagnosis
Determination

of serum calcium, phosphorus, and alkaline phosphatase levels and of the protein fractions is often helpful. A search for other foci of bone disease and for primary sites of malignancy or infection may lead to the proper diagnosis

Treatment
Exercises

to strengthen the muscles of the back and abdomen and to expand the chest will sometimes aid in accomplishing this

 In

more advanced cases it may be necessary to apply a light spinal brace or corset. A Thomas collar may be used to support the head and so relieve the constant dragging sensation.

Lordosis (Hollow Back)

Anteriorposterior

curvature of the spine in which the concavity is directed posteriorly is termed lordosis. Excessive lordosis is usually secondary to deformity elsewhere in the spine or in the lower limb.

 Two

common causes are abnormal dorsal kyphosis and hip flexion contracture. Patients with muscular dystrophy and paralysis of the gluteus maximus or erector spinae muscles stand with a marked lordosis. Abnormal lordosis is also associated with congenital dislocations of the hips.

Clinical Picture
The

patient stands with a hollow or swayback deformity. This may be associated with chronic low back pain.

Treatment
Correction

of the hip flexion contracture or the kyphosis. Strengthening exercises, especially of the abdominal and gluteal muscles are helpful.

Affections of the Thorax

Pigeon Breast (Pectus Carinatum)

The

sternum projects forward and downward like the keel of boat. This increases the anteroposterior diameter of the thorax, impairs the effectiveness of coughing and restricts the volume of ventilation.

Treatment
Mild

deformities can be made less noticeable by exercises that increase the strength and size of the pectoral muscles. The more severe deformities require thoracic surgery.

Funnel Chest (Pectus Excavatum)

The

sternum being pushed posteriorly by overgrowth of the ribs. The anteroposterior diameter of the thorax is decreased. The heart is often displaced into the left side of the chest

 Shortening

of the central tendon of the diaphragm has sometimes been considered the cause of the deformity, but there is little evidence to support this concept. The deformity may be associated with Marfans syndrome and with arthrogryposis

Treatment
In

mild cases exercises to improve posture and build up the shoulder girdle and pectoral muscles will greatly improve the patients appearance Swimming is especially helpful

Costal Chondritis (Tietzes Syndrome)

Tietzes Syndrome is a painful inflammatory lesion of the costochondral junction or occasionally of the manubriosternal or sternoclavicular joints. It affects young and middle-aged adults of either sex. The cause is unknown. The disease is self-limited. Local injection of procaine or hydrocortisone is required to relieve pain.