The scoliosis is a permanent deviation of the spine caused by a rotation of the vertebrae. It occurs mainly during childhood and adolescence but can also occur in adulthood. Girls are more at risk than boys and with a more important deviation of the spine. In addition, adolescence is a risky period because scoliosis can evolve slowly before development and aggravate as a result of a growth spurt.
In case of scoliosis, the spine or spine has a twist and its natural curves are modified . A deformation of the spinal column leads to an inevitable deformation of the ribcage, the classic hump. The hump is the deformation that develops from the side of the convexity of the curve and is evident during a flexion of the bust, the so-called “hump”.
In fact, the cause of scoliosis is not yet known, so the best weapon available to doctors is early diagnosis and prevention . Furthermore, the treatment depends on the severity of the curve and it is for this reason that it is important to treat scoliosis early.
Sometimes, the diagnosis is difficult because scoliosis does not present symptoms or particular pains. But, back pain and spinal observation can alert parents. In fact, the visible sign of the pathology is a malformation of the vertebral column, an incorrect posture and above all a hump on one side or the other of the column when the child bends forward (Adams test).
But, scoliosis cure is a long treatment that goes on for several years. If the curve is not too pronounced (curve of less than 20 degrees according to Cobb’s angle), the boy must be followed during the growth. But if the curve is greater than 35 degrees , surgery may be advised.
Scoliosis: what it is
Scoliosis is a lateral deviation and deformation of the spine . This condition cannot be changed voluntarily and is accompanied by anatomical changes in the vertebrae and adjacent structures, including organs.
In fiosological conditions, the column has a series of curves, lordosis and kyphos i, which allow it to better manage the loads and dissipate the forces. So, muscles and ligaments work synergistically on a symmetrical structure. But, in the presence of a scoliosis, in addition to the physiological curves, not always present, an anomalous lateral deviation is added often associated with a rotation of the group of deviated vertebrae.
Therefore, the biomechanics of the spine, of the musculoskeletal structures connected to it are altered and, in the most serious cases, this could create problems to the organs of the rib cage.
In fact, just think that only 25% of scoliosis is due to known causes while the remaining 75% has an unknown etiology (cause). In this case, it is called idiopathic scoliosis , that is, it occurs spontaneously without apparent causes.
Because of its complexity of management, it is today defined as ” three-dimensional torsional deformity of the spine and trunk ” (Grivas et al. 2006).
Difference between scoliosis and scoliotic attitude
It is good to clearly differentiate scoliosis from a scoliotic attitude . Scoliosis is a technical pathology defined as dysmorphism (morphological alteration), that is, it presents deformations from the anatomical point of view. While the scoliotic attitude is a paramorphism (taking incorrect positions) but it presents itself with a healthy and completely normal spine .
So, in the scoliotic attitude, there is a lateral deviation of the column but the vertebrae are neither rotated nor deformed.
Usually the cause of the scoliotic attitude is due to joint problems of the lower limbs, to their dysmetry or to postural alterations. Therefore, in this condition it is possible to solve the problem by solving the cause.
Only about 25% of scoliosis have a precise, pathological or functional cause. Instead, the remaining 75% is made up of idiopathic scoliosis.
Furthermore, its frequency seems to vary according to latitude and has a percentage between 0.93% and 12% of the general population with a Cobb angle greater than 10 °.
Scoliosis: historical notes
Scoliosis affects humans from the moment they move to a standing position.
Hence, it is a well known problem from ancient times. Hippocrates studied scoliosis and applied it to its measurement, later drawing up a classification . Furthermore, he developed some deformity correction techniques based on still current principles.
However, the term scoliosis was first mentioned by the Greek physician Galene in the 2nd century BC. The first rudimentary metal corsets were conceived in the 16th century by Ambroise Pare. The scientific breakthrough came with the introduction of X-rays in diagnostics in the early 1900s.
After about 30 years, in 1931, Hubbs performed the first spinal arthrodesis and in 1946 the first corset (Milwaukee) was created by Schimdt and Blount which associated the axial traction of the column with lateral pressers. So, let’s get to the 60s with Harrington’s first modern surgical treatment.
The vertebral column is made up of 33 vertebrae and is divided into the cervical, dorsal, lumbar, sacral and coccygeal tracts.
In general, a vertebra has a body, anteriorly, and vertebral arches posteriorly. These two structures delimit the medullary canal within which the spinal cord resides.
The vertebrae are connected to each other thanks to the intervertebral disc , with the function of bearing and nourishment for the vertebra, and to the joints placed on the vertebral arches.
A hole is formed between two vertebrae to allow the spinal nerves to come out of the medulla, the intervertebral hole . The vertebrae have evolved to work in synergy and offer the spine flexibility but at the same time robustness .
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The physiological curves of the spine play a key role in these characteristics :
- cervical lordosis
- dorsal kyphosis
- lumbar lordosis
- sacral kyphosis.
Physiological curves have the function of dissipating forces and managing loads in the best way , together with the deep muscles of the back and postural muscles affect the posture of the body as a whole.
But, when this balance of forces and tensions is lost , for example for a scoliosis , the biomechanical model of the body loses its effectiveness and goes through a series of adaptation attempts that could also lead to serious problems for the patient.
Scoliosis: primitive and secondary curve
Scoliosis is a highly complex disease but its pathological anatomy has well-defined characteristics: the main or primitive curvature is the one that presents the greatest structural alterations of the spine.
Hence, it is the direct result of the triggering cause, although in idiopathic scoliosis the real etiology remains unknown. The primitive curve can affect any stretch of the spine. Instead, the secondary or compensation curvature develops in the areas above and below the primitive curve.
The purpose of the secondary curve is precisely to compensate the degrees of the primitive curve. Hence, both curves are affected by a rotation of the individual vertebrae on its axis with the direction of the vertebral body towards the convex side of the curve.
Furthermore, each curve has an apical vertebra which, as the word suggests, being placed at the apex of the curve is consequently the vertebra which has the greatest structural alterations. If at the “center” of the curvature we find the apical vertebra, at the extremes we find instead the extreme vertebrae , that is vertebrae of “passage” between the main and secondary curve.
Furthermore, in cases of severe deformation of the thoracic cavity , there is the possibility of developing modifications to the organs present inside it. It is important to remember that scoliosis can be idiopathic and therefore with a strong possibility of evolution in adolescence or a scoliosis with known etiopathology (causes).
We have anticipated how scoliosis can have a known cause: congenital, neuromuscular, secondary to other pathologies or dysmetries, scoliotic or functional attitude.
Instead, a percentage of scoliosis does not have a clear origin, in this case we are talking about idiopathic scoliosis which covers the largest percentage of structured scoliosis.
By structured scoliosis we mean a pathology that has all the deviation and rotational characteristics.
Furthermore, among the structures we find those with congenital and neuromuscular etiology . Instead, unstructured scoliosis has an incomplete rotational component and for this reason they can be called postural. In addition, this group includes:
- functional scoliosis
- scoliotic attitudes
- scoliosis secondary to other pathologies.
It represents about 75% of all scoliosis.
The causes are not known and therefore only conceivable. But, the disease still has a strong multifactorial genetic component . For example, a child with a scoliotic parent has a much greater chance of contracting the disease than a child with a non-scoliotic parent.
There are several studies that highlight possible, but not yet defined, causes of idiopathic scoliosis. The genetic factor, alterations of the central nervous system, alteration of growth hormone and biomechanical alterations seem to be involved in the development of this type of scoliosis.
In fact, the central nervous system controls movement, posture and regulates muscle tone. But, its malfunction could lead to disturbances of the postural system , coordination and body orientation in space. The result would be a distortion of the body pattern during growth . This could lead to a lack of control by the central nervous system of the curves of the spinal column during growth.
What’s going on in development
So, it would seem that during the growth, the musculoskeletal structure triggers a series of “malfunctions” of the development of the tissues. These disturbances would start the formation of the scoliotic curve that leads to create a real vicious circle with a consequent evolution of the curve and therefore its worsening.
Evolution continues throughout the development phase until skeletal maturity is reached.
The greater incidence in the female sex has led to think of hormonal alterations , but still remains a hypothesis. There are other hypotheses on the origin of scoliosis but that of the alteration of the central nervous system is the one that has found a greater consensus among scientists.
The authors Sahlstrand and Nachemson have defined idiopathic scoliosis as “a multifactorial disease in which an abnormal mutation of the Central Nervous System genetically determined participates, associated with a misalignment of the skeleton due to the difference in growth of the different vertebral elements, on which biochemical and neuromuscular factors act. , for which it is difficult to establish whether they are causes or consequences ”.
Scoliosis of known etiology
In this case, the pathology has known causes and is secondary to malformations or other pathologies.
For example, malformations or dysmetries of the lower limbs, myopathies (muscular dystrophy) and pathologies of the vertebrae (spondyloarthritis) are just some of the multiple causes that can lead to scoliosis.
In fact, many syndromes affecting the skeletal muscle system, or affecting the nervous system and, not least, neoplasms can also lead to the development of a scoliosis.
The methods of classification of scoliosis are different but the most used are those relating to location and causes (etiology). Following the location criterion, we find scoliosis with a primary curve :
- dorsal cervico.
This category, scoliosis with a primary curve, represents 70% of cases. The dorsal and lumbar ones are the most common. The remaining 30% of scoliosis is represented by a double primary curve. So, we find those:
- dorsal and lumbar
- with double back curve
- dorsal and dorso-lumbar.
In addition, by examining the classification by etiological agents (causes), scoliosis is divided into three categories :
- idiopathic (of unknown origin).
About 70% of scoliosis are classified as idiopathic, i.e. without a known origin. The remaining 30% is divided between congenital and acquired form. The congenital form is present from birth and related to other uncommon or rare pathologies. Instead, the acquired form is the consequence of pathologies, traumatic or neuromuscular lesions (for example poliomyelitis).
Both types (idiopathic and with known etiology) can also evolve from the symptomatological point of view.
Furthermore, if the exponential worsening occurs in adolescence and then slows down in adulthood, the path of symptoms can be very different.
If a child / adolescent is better able to compensate for the ailments caused by scoliosis, this ability is progressively limited with age.
Hence, it is likely that adults may experience more symptoms than teenagers due to the natural aging process of the human body. Some of the natural degenerative processes that, in association with a deformation of the spinal column, can lead to serious symptoms, are:
- limited mobility
- circulatory problems
- deterioration of the intervertebral discs.
The most frequent pains encountered are pains in the lumbar spine and lower back, often associated with widespread stiffness in the area.
In addition, if the scoliosis involved has an impairment of the vertebral canal and therefore a compression of the spinal nerves, symptoms similar to disc herniation may occur :
- electric shock pain in the lower limbs
- loss of strength and acute pain.
Therefore, the muscle imbalance associated with the pathology can lead to a worse biomechanical efficiency of joints and muscles with a consequent muscle fatigue .
The clinical picture of scoliosis is typical but it is essential to carefully evaluate the type of scoliosis to arrive at a correct diagnosis.
In fact, underestimating a highly evolutionary idiopathic scoliosis could lead to dramatic physical and psychological consequences in the affected person.
Instead, a scoliotic attitude caused by a postural vice but mistaken for a scoliosis, can lead to long and expensive unnecessary therapies. Therefore, the diagnosis must be made by a specialist doctor who will request the necessary instrumental tests.
Cobb’s angle is an index of evaluation of scoliosis that we will deepen in the next paragraphs. Of the diagnosed scoliosis cases, approximately 10% require conservative treatment and approximately 0.2% require surgery.
The latter could be expected when the Cobb angle is greater than 30 ° -50 ° (depending on the authors) because such a deformity would increase the risk of health problems and reduce the quality of life. The evolution of idiopathic scoliosis is more pronounced and frequent in females than in males.
A standing radiographic examination (orthostatism) is necessary to evaluate and measure the scoliotic curves, classify the pathology and organize the therapeutic path. In fact, thanks to the radiographic examination it is possible to calculate the Cobb angle , that is the angle of curvature to evaluate the severity of the pathology. It is generally the Cobb angle that determines the type of therapeutic intervention.
In fact, surgical intervention is foreseen in scoliosis with a Cobb angle greater than 40 °, a corrective corset between 20 ° and 40 °, while under 20 ° the therapy does not include the use of corsets.
Finally, it is finally called scoliosis when the Cobb angle measures more than 5 °. In addition, the diagnostic process involves a careful history and a series of clinical tests. The Cobb angle is an examination that involves a measurement in two dimensions. Therefore, it does not take into account a series of variables, such as the aesthetic impact of the pathology.
Instead, the Adams test is used in the clinic to measure the extent of deformation and asymmetries. In orthostatic position, the patient is asked to flex his torso and bring his hands close to the toes.
With this movement the deformation of the scoliotic tract (hump) is emphasized and its severity can be assessed with the scoliosometer.
However, the Adams test as well as the calculation of the Cobb angle have some limitations. First of all, some studies report a dubious reliability of the test to measure the actual rotation of the vertebral tract. In addition, the measurements with the scoliosometer are often inaccurate and difficult to reprecise, the risk is to underestimate the severity of the pathology.
In both cases, the Cobb angle and the Adams test, it would be appropriate to integrate the measurements with a rasterstereography, or a three-dimensional acquisition of the image of the trunk, which allows precisely an assessment of the deformation in three dimensions.
The evolution of scoliosis depends on many variables and can reach 20 ° Cobb per year. We know that it reaches its peak in the growth phase between 11-17 years but also that, basically, a short curve has a faster evolution.
Once it reaches bone maturity, it stabilizes but could continue to worsen even in adults. Usually a worsening of Cobb degrees in adulthood is found in curves over 40 °.
Basically it is impossible to accurately predict the progress of the pathology, for this reason early diagnosis is vital. The earlier the scoliosis is diagnosed, the higher the chances of success in treatment.
Scoliosis treatment is based on: assessment of the severity and position of the curve, age, sex, bone maturity and symptoms.
Basically with a scoliotic curve up to 20 ° there are no corsets but only motor activity aimed at strengthening the deep muscles of the back.
Instead, with a curve between 20 ° and 35 ° the application of an orthopedic corset or bust is provided. Beyond 35 ° -40 ° of curvature , surgery will be required.
1 – Treatment of scoliosis below 20 ° Cobb angle
Therapy is basically observation, with monitoring of the evolution of the curves every 6 months . Postural gymnastics and physical activity are the forms of intervention proposed in this phase.
2 – Cobb angle between 20 ° and 35 °
Scoliosis included in these grades can be treated with two different types of therapy:
- bloody (surgery).
Medical evaluation will determine the therapeutic path.
Orthopedic and physiotherapy therapy
The nonoperative therapy is indicated in adolescents and scoliosis of less than 30 ° with vertebral rotation and contained a low risk of evolution. In these cases, the goal is not to make the situation worse by taking advantage of orthopedic, physiotherapy and sport therapies.
Then, the orthopedist intervenes by using busts and corsets to immobilize the spine and try to prevent the worsening of the pathology.
On the market there are different models of corsets and their use is specific for each category of scoliosis. Basically the models are of three types.
- Milwaukee, suitable for any form of scoliosis
- Lionese suitable for the forms of back or back-lumbar scoliosis
- Lapadula indicated instead for the lumbar curves.
The corset is a therapeutic means that can only be used in children and is ineffective in adulthood.
The initial phase involves wearing the corset 24 hours a day, with a progressive decrease in the hours in the subsequent phases.
However, it becomes almost obvious to mention the psychophysical implications that a corset can have on a child / boy. In addition to psychological and social problems, the corset can cause:
- rigidity of the spine
- muscle wasting
- dental malocclusion problems in Milwaukee.
Electrical stimulation and physiotherapy
Also for these reasons, non-invasive methods such as electrical stimulation (LEES) have been developed in recent years. A technique that could prove to be a valid alternative to corsets in the near future. It involves the application of electrodes on the convex side of the curve for 8-10 hours a day, at night. Instead, physiotherapy aims to limit the possible damage caused by corsets, improving joint mobility, limiting muscle atrophy and improving the general condition of the child / boy. Finally, physical activity.
Sport plays a key role both psycho-social and physical. It improves muscle trophism, vital during corset therapy, improves the mobility of the spine and joints as a whole, as well as coordination and proprioception.
The recommended sports are all those that provide for global activation of the muscles , it is appropriate to choose them based on the patient’s attitudes and preferences. There is no clearly better sport than the others, the important thing is to practice it (to the extent possible) with perseverance, passion and that leads to personal satisfaction .
Instead, corrective gymnastics is misleading in its name. Of corrective it has only the name, because in concrete it is not possible to correct an idiopathic scoliosis only with gymnastics.
3 – Scoliosis greater than 35 ° -40 °
In these cases, the only possibility of intervention is bloody therapy , surgical intervention.
A severe scoliosis or in rapid evolution must be corrected to avoid causing serious damage to the patient. But, the surgery is more effective if performed between 12 and 16 years , with a scoliosis being developed but with a bone maturity that is not yet complete.
Hence, this does not mean that surgery cannot be performed in childhood or adulthood. The variables involved are many and above all unpredictable. Also in this case there are different methods of surgery. Among the best known and oldest we find the Risser method .
The patient arrives for surgery after several months of pinstripe bust . The intervention involves an arthrodesis (fixation) of the vertebrae that present rotation and deformity and the vertebrae bordering on the extreme ones at the curve. Then, the column is fixed, tensioned and the curve corrected. The post-intervention reintroduces the bust pinstripe maintained for about a year.
Scoliosis cannot be prevented. In fact, it is clear that it is not possible to prevent a pathology with unknown cause, genetic or secondary to other pathologies.
However, it can be prevented, in some cases, from worsening. Physical activity plays a key role in the prevention of osteoarticular symptoms and problems in cases of mild scoliosis. Scoliosis leads to an inevitable muscle imbalance and a change in joint biomechanics. Some imbalances can be limited with physical activity , and this must not necessarily be specific to scoliosis. Let us remember that we are talking about unstructured scoliosis and therefore of children and adolescents .
Sports and children
The selection of physical activity must also be done according to the needs of the child , also because studies are contradictory on the real effectiveness of gymnastics for the improvement of scoliosis. If we wanted to describe an “ideal” physical activity for scoliosis, taking into account all the factors characterizing the pathology, we could describe it as an activity under load (no swimming), which requires coordination skills and reflexes , with wide movements and use of different engine patterns.
For example, team games such as volleyball and basketball or an individual sport such as sport climbing.
Instead, sports where an excessive increase in flexibility such as artistic gymnastics and dance , for example , should be avoided . The reason is the risk of worsening of the curves due to the increase in flexibility of all muscles, including those in shortening that keep the curve “stable”.
Swimming yes, swimming no?
We come instead to swimming. The cure for all ills according to hypotheses now denied. Swimming, being a sport practiced in water and therefore in discharge, with continuous torsions of the bust, not only would not bring benefits in patients with scoliosis but would even be counterproductive .
according to a reliable cross-sectional investigation”.Swimming is not a treatment for scoliosis
However, since scoliosis is a very complex pathology, there are no standard exercises but these must be recommended by expert personnel and on medical advice. Furthermore, remember that corrective gymnastics does not aim to correct curves but to limit their worsening. Therefore, the exercises must be carried out under the supervision of an expert , who will select the most appropriate movements according to the medical indications to favor a physiological functionality of the spine.
Scoliosis Research Society- SRS .