Affections of the Spine and Thorax

7/29/2019 Affections of the Spine and Thorax

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Affections of theSpine and Thorax


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Affections of thespine


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SCOLIOSISScoliosis is a lateral curvature of

the spine.It is a deformity rather than a

disease.


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Nonstructural ScoliosisOne large group of scoliosis

patients is made up of those whose

spinal curvatures is the result oftemporary postural influences.


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It is not accompanied by rotational

or asymmetric changes in theindividual structures of spine.The curve is not fixed; the patient

can actively and completely correctthe deformity by sitting erect.


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It may result from poor posture or

leg length discrepancies and usuallyposes no major therapeuticproblem.

A non-structural scoliosis may alsobe caused by nerve root irritationsuch as the sciatic scoliosis seen in

acute lumbar disk herniation.


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Structural ScoliosisIs characterized by definite

morphologic abnormalities,

therapeutic effort is mostconcerned.


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Congenital Scoliosisis caused by adefect in embryologic development

of the vertebrae or ribs, such ashemivertebra.


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Neuromuscular Scoliosisisassociated with a great variety of

paralytic disorder that causesasymmetric paralysis of the trunkmuscles.


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It occurs also in neurofibromatosis;

in skeletal diseases such asosteogenesis imperfecta, Marfanssyndrome, and osteomalacia;

especially conditions such asunilateral thoracic conditions suchas thoracoplasty and chronicempyema.


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Pathogenesis is unknown. Suchcases are classified as idiopathic

scoliosis.


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PathologyAll the structure of the concave

side are compressed or shortened,

whereas those in the convex sidemay remain normal of becomelengthened.


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The apical vertebra, situated atthe middle of the curve, shows the

greatest change.


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The intervertebral disks arecompressed on the side of the

concavity and may bulge onopposite side as a result of thepressure; the nucleus pulposus

migrates toward the convex side.


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The anterior longitudinal ligamentis thickened on the concave side

and thinned on the convex side.


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Malalignment of the spinal jointsleads to degenerative arthritic

changes in later life.


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The rotation, which is greatest inthe apical vertebra, vertebral

body always turns toward theconvex side of the curve, spinousprocess toward the concavity.


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In a posterior rotation of the chestwall, a posterior prominence of the

rib cage on the convex side of thecurve, and an anterior prominenceof the thorax on the concave side.


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Cardiopulmonary failure is afrequent cause of death in patients

with severe scoliosis.


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Significant changes in pulmonaryfunction are usually not apparent

in curves under 55 degrees. At 100degrees the patient often becomessymptomatic.


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Roentgenographic PictureA major, or primary, curve, which

is usually the largest and most

rigid, is generally accompanied byminor, or compensatory, curvesabove and below.


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The minor curves are more flexibleand show fewer structural

changes. Those in the thoracic andcervical regions tend to be mostrigid and deforming.


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The Cobb method of

measurement is the most widelyaccepted technique.Anteroposterior view of theentire spine made with thepatient bending as far aspossible to the left and to theright gives evidence of the

flexibility of major and minorcurves.


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A lateral roentgenogram of the

spine demonstrates kyphoticand lordotic curves and detectsspondylolisthesis sometimesassociated with scoliosis.Protective shields placed overthe breasts and thyroid hasbeen recommended by some toreduce repeated radiationexposure of these organs.


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Idiopathic ScoliosisIdiopathic Scoliosis encountered in

adolescents is the most common. It

is seen predominantly in girls andis associated with a significantfamilial occurrence.


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Hypotheses of etiology, includingunrecognized paralysis,

asymmetric growth of vertebralepiphyseal plates, and minordisorders of proprioception and

balance associated withlabyrinthine disorders.


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An infantiletype of IdiopathicScoliosis, uncommon to US, affects

boys more frequently than girlsand resolves spontaneously in mostinstances.


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A juvenile variety, of equal sexdistribution and beginning

between 3 years of age and theonset of puberty.


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Clinical PictureAs a rule there is no complaint

until the deformity of the back is

noticed.very gradualdevelopment. The patient may bebrought to the physician because

of a high shoulder, a prominenthip, or a projecting shoulderblade.


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Occasionally the child may complain

of fatigue and backache before adeformity is noted. There may beshortness of breath from diminished

respiratory capacity andgastrointestinal disturbances fromcrowding of the abdominal organs.


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Viewed from the back, the mostprominent features are the spinal

curvature, asymmetric flank foldsin the presence of a level pelvis,and prominence of the scapula and

shoulder on the convex side of thecurve.


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In adolescent idiopathic scoliosisthe thoracic curve is usually

convex to the right and the lumbarcurve to the left.


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In the lumbar area, spinal rotationresults in prominence of the

paravertebral muscles on theconvex side, while in the thoracicregion rotation of the rib cage

elevates the scapula and shoulder.


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A plumbline dropped from thespinous process of C7 should pass

through the intergluteal crease. Ifthe line falls to one side of thecrease, the scoliosis is

uncompensated.


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DiagnosisIdiopathic scoliosis is diagnosed be

exclusion. The neurologic findings

should be normal, limb lengthsequal, and manifestations ofcongenital disorders or systematic

disease absent.


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PrognosisAmong the large majority of

adolescent children in whom

structural scoliosis is detected inroutine school screeningprograms, significant progression

of the spinal curve does not occur.


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If the curve is greater than 20 to30 degrees and the child still has

several years to grow whendeformity is first detected, thechances of progression are

increased. Thoracic and doubleprimary curves are more likely toprogress than are lower curves.


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Curves greater than 40 degrees atmaturity, however, may continue

to progress in adult life, althoughusually at a slower rate.


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TreatmentMany persons with idiopathic

scoliosis will not require definitive

treatment. Cosmeticconsiderations often influence thedecision.


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Thoracic curves that exceed 35degrees are cosmetically

unacceptable. The basic aims torecognize curvature early, toevaluate its chance of progressing

accurately, and insofar as possibleto correct it and maintain itscorrection.


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Nonsurgical MeasuresTwo types of nonsurgical

treatment; First consists of

exercises and observation. Thistreatment is reserved for mildcases with flexible curves less than

20 degrees or perhaps a littlemore if the patient is nearmaturity.


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Exercises have not been shown toexert any lasting corrective

influence on a structural curve,but they may serve to maintainspinal flexibility. If there should be

any sign of progression, moreaggressive treatment is indicated.


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The second nonsurgical treatment isthe use of braces. Most effective useis the Milwaukee, or Blount, brace.It incorporates both activedistractions, encouraged by

adjustable uprights extending fromhead to pelvis, and adjustableposterolateral pressure over the

thoracic prominence.


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The brace is worn for 23 hours aday and removed for 1 hour for

bathing, skin care, and additionalexercises.


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Early progressive but flexiblecurves of young children of 20 to

40 degrees, the Milwaukee bracecan be used to correct andmaintain correction of the

deformity. It is not effective incurves of over 40 to 50 degrees.


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The brace must be worn until alltendencies toward increase of the

curvature have ceased. Bracingmust usually be continued untilskeletal maturity, demonstrated by

closure of the vertebral and iliacapophyses. In the final months thebrace is worn only at night


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Since possible complications ofwearing the brace include skin

allergies, pressure sores, andemotional disturbances, thepatient should be seen at frequent

intervals.


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The shorter braces are mosteffective in the treatment of

flexible lower curves of less than40 degrees


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Surgical MeasuresSurgical treatment is indicated

when curvatures of unacceptable

degree cannot be satisfactorilyimproved or their improvementsatisfactorily maintained by

nonsurgical measures.


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Progressive curves of more than45 degrees on children who are

still growing are best treatedsurgically. Only about 5% of thecases of idiopathic scoliosis are

severe enough to require spinalfusion.


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Spinal arthrodesis is the mosteffective means of permanently

maintaining correction of thecurvature.


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The surgical correction of severecurvature may be facilitated by

Inserting the metal distractionrods devised by Harrington; inaddition to these devices,

however, spinal fusion necessary


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Spinal fusion for scoliosis must befollowed by a period of

immobilization in a plaster cast orbrace for 6 to 9 months


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Congenital ScoliosisCongenital scoliosis is caused by

abnormalities in the development

of the vertebrae. Embryonicanomalies result from failure ofportions of the vertebrae to form(hemivertebra), from failure of

segmentation (seperation) of thevertebrae, or from a combinationof these factors.


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Two or more vertebral bodiesunited in a single mass of bone

called block vertebrae. The spinalcurves of congenital scoliosis tendto be more rigid than those of

other forms of scoliosis.


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Congenital scoliosis is oftenassociated with other congenital

anomalies. These include spinabifida occulta, diastematomyelia,congenital heart defects, and

anomalies of the genitourinarytract.


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TreatmentIt must begin much earlier and

must continue for a much longer

period. It is important to institutetreatment early and not to permitthe deformity to progress.


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When spinal growth is completelytethered on one side, as by a

unilateral bar, continuedunilateral growth can result onlyin progress deformity. Posterior

spinal fusion is indicated at a veryearly age in these patients.


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When severe deformity is present,limited correction can be gained by

means of traction methods such as halo-femoral traction. Harringtoninstrumentation is probably bestavoided in operations for congenital

scoliosis, since any sudden correction ofthe deformity may injure the spinalcord.

N l S li i


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Neuromuscular Scoliosis

(Paralytic Scoliosis)Neuromuscular Scoliosis is the

result of asymmetric paralysis ofmuscles that stabilize the spine.


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It may develop in a great variety ofneurologic disorders and can

progress to severe collapse of thespinal column, impairing thepatients respiratory function and

ability to sit and stand.


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It is encountered most frequentlyin stable or slowly progressive

neuromuscular affections.Paralytic scoliosis is common inpatients with Friedreichs ataxia,

severe myelomeningocele, andCharcot-Marie-Tooth Disease.


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Every early paralytic spinal curveis likely to progress. In paralytic

scoliosis the prognosis isdetermined by the primaryneurologic disorder.


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TreatmentIn patients with partial paralysis of

the muscles of respiration,

pressure on the thorax by a cast orbrace is poorly tolerated. Whereskin is anesthetic, braces may

cause pressure necrosis.


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When the deformity is progressingor when sitting ability or

respiratory function isdeteriorating, surgical treatmentof neuromuscular scoliosis is

usually indicated.


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Preliminary improvement of severecurves may be accomplished by

halo-femoral traction. Harringtoninstrumentation is extremelyhelpful in paralytic scoliosis.


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Spine stabilization by segmentalwiring of each lamina to the

heavier Luque rods has beeneffective in paralytic scoliosis.Occasionally, in very severecurves, posterior spinal fusion

should be supplemented byanterior fusion of the vertebralbodies as described by Dwyer.


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Frequently patients requiretracheostomy and respiratory

support during the operation andthe immediate post-operativeperiod.


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KyphosisAnteroposterior curvature of the

spine in which the convexity is

directed posteriorly. Posteriorconvexity of an abnormal degreefrom pathologic changes located

primarily in the vertebral bodies,the intervertebral disks, or thesupporting musculature.


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Kyphotic deformity occurs notuncommonly in children and young

adults. The most frequent cause isfaulty posture. Severe kyphosismay develop in the lumbar or

lumbodorsal region of patientswith myelomeningocele.


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Kyphotic deformity seen in middleor late age groups has been called

adult round back. Its causesinclude postural influences andcommon bone and joint diseases, as

well as degenerative spinal lesionspeculiar to adult years.


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Any condition causing anteriorwedging or collapse of the

vertebral bodies may result inkyphosis. The most common ofthese are osteoporosis of any form,

metastatic cancer, trauma, andinfection.

Adolescent Kyphosis


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Adolescent Kyphosis(Scheuermanns Disease, JuvenileKyphosis, Vertebral Epiphysitis)

The term adolescent kyphosishas

been applied to a chronic affectionof the vertebral bodies evidencedclinically by the gradualdevelopment of a fixed kyphosis,

with which back pain may or maynot be associated. The onsetusually takes place in the earlyteens.


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The process always involves threeor more contiguous vertebrae and

usually is most advanced in thelower or middle portion of thedorsal spine. It is seen with about

equal frequency in boys and girls.


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EtiologyScheuermann believed the cause

to be a growth disturbance of what

he termed the vertebralepiphyses. Frequent finding ofirregular thinness in the vertebral

end plates and protrusion of thenucleus pulposus into thevertebral bodies in this condition.


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The cause is congenital deficiencyin the thickness of the vertebral

plates and that partial loss of disksubstance causes excessivepressure on the anterior portion

of the vertebral epiphyses.


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Roentgenographic PictureBone edges above and below the

intervertebral spaces are ill

defined and of uneven density. Thevertebral end plates are irregularin outline.

A h l k l h


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As healing takes place, thefragmentation disappears, and the

bone outlines become relativelymore distinct but remain irregular.The most outstanding

Roentgenographic feature isanterior wedging of the vertebralbodies as seen in the lateral view.

Most normal children such cleftsdisappear before the tenth year ofage.


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Clinical PictureThe symptoms usually begin the

ages of 12 and 16 years. The first

subjective evidence may be fatigueand pain in the back.


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Undue prominence of the spinousprocesses of the vertebrae may be

noticed, especially at the lowerdorsal and upper lumbar levels,and a gradual increase in kyphosistakes place. Compensatory

increase of lumbar lordosis is afrequent finding, and hamstringtightness is often associated.


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Stiffness and tenderness may bepresent throughout the spine. A

mild degree of scoliosis is oftenassociated with adolescentkyphosis. In later years

osteoarthritic changes andbackache may develop.


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DiagnosisAdolescent kyphosis is to be

distinguished from tuberculosis

and other inflammatory orneoplastic conditions that causevertebral collapse. It is usuallyassociated with more pain and

muscle spasm, with bonedestruction and with systemicsymptoms not found inScheuermanns Disease


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TreatmentIn milder cases it may be advisable

to have the patient limit activities

that put stresses on the spine, usea fracture board without pillow,and carry out kyphosis exercises.


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The most effective form oftreatment is the Milwaukee brace.

It is usually necessary to continuebrace treatment for 1 to 2 years.Persistent pain in later years is anindication for posterior spinalarthrodesis and use of Harringtoncompression rods.

Vertebr Pl (E i hili


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Vertebra Plana (EosinophilicGranuloma, Calves Disease)

Vertebra Plana is an uncommon

affection, occurring usually in thedorsal spine of children between 2and 12 years of age andcharacterized by pathologicchanges localized in a singlevertebral body.


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Roentgenographic PictureVertebral body may appear

fragmented or eroded. Adjacent

disk spaces are normal orthickened. With healing, theaffected body becomes normal indensity.


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Clinical PicturePain, fatigue, and mils angular

kyphosis are characteristics

muscle spasm and tenderness mayalso be present


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DiagnosisDifferential diagnosis should

include Eosinophilic Granuloma,

tuberculosis, tumor, compressionfracture and congenital anomaly.Biopsy may be advisable


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TreatmentRest in recumbency is indicated

until the diagnosis has been made

and the pain has subsided.

Adult Kyphosis


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Adult KyphosisEtiology Adult Kyphosis may be producedby faulty posture, degeneration of

the intervertebral disk, atrophy

and collapse of the vertebralbodies, pathologic entity such aschronic arthritis, osteitisdeformans, poliomyelitis, facture,

metastatic tumor, plasma cellmyeloma, tuberculosis, or otherdisease affecting the vertebralbodies or disks.


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Degeneration and thinning of theintervertebral disk sometimes take

place in middle life; this processmay progress to cause a single,long kyphosis with flattening of thelumbar and cervical portions andforward projection of the head.


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PathologyIn adult kyphosis caused by lesions

of the intervertebral

fibrocartilages, the pathologicchanges that occur in the disks arecharacteristic. Two thin plates ofhyaline cartilage separate the diskfrom the bones above and below

I 30% f ll d lt i l li d


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In 30% of all adult spines, localizedprotrusions of nuclear materialthrough the cartilage plates andinto the spongy bone of thevertebral bodies have been foundGradual thinning or collapse of theintervertebral disks allows adjacent

vertebral bodies to become

approximated


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In adult kyphosis from senileosteoporosis, the disks remain

relatively normal but the spongybone within the vertebral bodybecome atrophic and the cortexbecomes thinned


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In the thoracic spine the vertebralbodies may become wedge shaped,

lumbar region they may assume abiconcave or hourglass contour asseen in lateral roentgenograms.The osteoporosis may lead topathologic compression fractures.


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Clinical PictureIt may or may not associate with

pain, weakness of the back, and

general fatigue. The aching andtiring of the back usually occurbelow the apex of the kyphosis.


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DiagnosisDetermination of serum calcium,

phosphorus, and alkaline

phosphatase levels and of theprotein fractions is often helpful. Asearch for other foci of bonedisease and for primary sites ofmalignancy or infection may leadto the proper diagnosis


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TreatmentExercises to strengthen the

muscles of the back and abdomen

and to expand the chest willsometimes aid in accomplishing this


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In more advanced cases it may benecessary to apply a light spinal

brace or corset. A Thomas collarmay be used to support the headand so relieve the constantdragging sensation.


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Lordosis (Hollow Back)Anteriorposterior curvature of

the spine in which the concavity is

directed posteriorly is termedlordosis. Excessive lordosis isusually secondary to deformityelsewhere in the spine or in thelower limb.


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Two common causes are abnormaldorsal kyphosis and hip flexioncontracture. Patients withmuscular dystrophy and paralysisof the gluteus maximus or erectorspinae muscles stand with a marked

lordosis. Abnormal lordosis is alsoassociated with congenitaldislocations of the hips.


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Clinical PictureThe patient stands with a hollow or

swayback deformity. This may be

associated with chronic low backpain.


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TreatmentCorrection of the hip flexion

contracture or the kyphosis.

Strengthening exercises,especially of the abdominal andgluteal muscles are helpful.


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Affections of theThorax

Pigeon Breast (Pectus


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Pigeon reast (PectusCarinatum)

The sternum projects forward anddownward like the keel of boat.

This increases the anteroposteriordiameter of the thorax, impairs theeffectiveness of coughing andrestricts the volume of ventilation.


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TreatmentMild deformities can be made less

noticeable by exercises that

increase the strength and size ofthe pectoral muscles. The moresevere deformities requirethoracic surgery.

Funnel Chest (Pectus


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e est ( e t sExcavatum)

The sternum being pushedposteriorly by overgrowth of the

ribs. The anteroposterior diameterof the thorax is decreased. Theheart is often displaced into theleft side of the chest


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Shortening of the central tendonof the diaphragm has sometimes

been considered the cause of thedeformity, but there is littleevidence to support this concept.The deformity may be associatedwith Marfans syndrome and witharthrogryposis


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TreatmentIn mild cases exercises to improve

posture and build up the shoulder

girdle and pectoral muscles willgreatly improve the patientsappearance Swimming is especiallyhelpful

Costal Chondritis


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(Tietzes Syndrome)Tietzes Syndrome is a painful

inflammatory lesion of thecostochondral junction or occasionally

of the manubriosternal orsternoclavicular joints. It affects youngand middle-aged adults of either sex.The cause is unknown. The disease is

self-limited. Local injection of procaineor hydrocortisone is required torelieve pain.

Documents

Affections of the Spine and Thorax