SPINEThe spine and its most frequent diseases in

childhood

In childhood, the spinal diseases are the most frequent problems in the locomotors system.

 

The typical structural characteristic of the human body is the two-sided proportionality i.e. the bilateral symmetry. It means that the sagittal plane positioned at the middle of body — the median sagittal plane — divides the body into two equal part forming reflected images of each other.

The spine is in the intersection line of the frontal and the medial sagittal plane. Normally the spine is straight in the frontal plane.In the sagittal plane, however, curves of variable direction appear on the standing spine: the cervical lordosis, the dorsal kyphosis and the lumbar lordosis. These curves are physiological, the appearance of them are necessary, and within specific extent, normal.

The physiological curves are developing gradually from the infancy up to the full extent in the period after the puberty.

In older age, the curves usually increased due to the dehydration of the vertebral discs that fill ¼ part of the length of the spine.

The importance of physiologic curves• In mechanical respect: larger load bearing

capacity • In respect of statics: to ensure the equilibrium

The spine is not a single block. The vertebral column containing the vertebral bodies, joints and vertebral discs is a functional unit, called as - a kinetic chain.

From C3 to L4, the elementary structural design of the spine- can be modeled by means of three pillars where the first pillar is the vertebral body and the other two ones are the joint surfaces. i.e. the processus articulares.

The pillars of the elementary structures placed on the top of each other form vertical columns, and - at the same time – comparing to each other they are mobile segments having three joint surfaces.

The vertical stability of the spine is ensured by the connection of the elementary structures holding the gravitation force in all the physiological position of the body (R.Luis)

Although the spinal curves can modify the axes of the vertical columns under both dynamic and static circumstances, but not disturb the basic principle of the axial stability.

The spine has a very little internal stability in itself. To keep the equilibrium of the spine, the muscle system is necessary anyway. According to measurements, without an active muscle force – and the strengthening effect of ribs – the spine would be collapsed under the effect of an axial force as low as 20 N.

Compression forces and shearing forces act on the spine as a whole.

The compression force is held primarily by the trabecular structure of the vertebral body.

The intervertebral disc consists of three parts as follows:

• anulus fibrosus, - is built up from collagen fibers of type different in childhood from those in adult age,

• nucleus pulposus• cartilaginous plate.

The anulus fibrosus consists of concentric ring shaped plates of the horizontal plane. Their fibers are look like the layers of onion.A nucleus pulposus is a very hydrophilic loose fibrillar structure with 85% water content, consisting of mucopolysaccharids and collagen fibers that occupies the central part of anulus fibrosus. The cartilaginous plate ensures the origin of the fibers of the anulus fibrosus and the diffusion of liquid from the blood circulation for filling up the nucleus pulposus.

The discus bears the axial compression acting on it through the osmotic pressure of the well- hydrated nucleus. In case of increase in load, the nucleus loses water until a new equilibrium is established.

In case of cyclic repetition of the compression forces the water loss continues at a highly increased rate. Examinations show that the high loss of nucleus during standing of one and a half an hour can be normalized in lying position within 15 minutes.

As the spine consists of 3 vertical columns, all the three joint surfaces in each mobile segment – the discus and the two rear joints- bear the forces in common.   In standing position, the resultant of the gravitation force acting in front of the spine as well as the muscle force balancing it behind the spine exerts compression force on the discus and the vertebral body and shearing force on the rear joints.

As the load acting on the spine is increased towards caudal, accordingly, the whole joint surface is also increased towards caudal in each mobile segment.

The intervertebral discs are also the largest ones in the lumbar region; their height lies between 10 and 15 mm and their surface is 50 x 30 mm in case of adults.

The motions of the spinal column depend on the structure of its joints.Each mobile segment includes three joints according to the three pillars.

The discus in itself could be function as a ball joint, with optional number of motional axis, however

The mechanism of two joints formed by the same bone in part shall be common, that is, the axle of motion shall meet the geometric conditions of both joints. This is the common axle of temporary arrangement. / Szentágothai/

Thus, the motions are always determined by the common axis of temporary arrangement, or more than this, —as the structure of the discs is the same in each segment — depending of the planes of the processus articulares.

The rear small joints (zygoapophysealis articulation):according to their mechanisms, they are trochoids, or pivotal joints.The planes of rear joints are different in the various sections of the spine:they are located - in the cervical spine in the horizontal plane,- in the dorsal section in the frontal plane,- in the lumbar section in the sagittal plane.

Accordingly, the motions of the spine – flexion-extension, rotation as well as the inclination – are occur in different manner and to different extent in the various sections of the spine.

The flexion – extension that takes place in the sagittal plane is a circular motion around a transversal axle. On the lumbar spine, this motion is of the largest range

The rotation • in the cervical spine follows an elliptical

segment,• in the thoracic spine the joint surfaces are

rotated along an arc. In the thoracic section, this form of motion is the freest one; the others are restricted due to the connection of ribs.

• in the lumbar region the rotation is significantly restricted due to the sagittal position of rear joints.

A lateral-inclination is connected with simultaneous rotation.This, and any other forms of motion are the freest ones in the cervical spine.

Each mobile segment composed of two neighboring vertebra is able to do motions of small amplitude. Adding up of these motions results in the considerable mobility of the spine functioning as a kinetic chain.

The static function of the spine is to ensure the equilibrium of the head and the trunk by means of the physiologic curves established in the sagittal plane .

Stand The position standing on two legs is a human-specific posture.

The position of equilibrium is structurally determined. The vertical — anti-gravitational — posture is guaranteed by the myotatic or proprioceptive reflex controlling the length of the skeletal muscle, thereby the position of the joint.

The sagittal plane positioned at the middle of body — the median sagittal plane — divides the body into two equal part forming reflected images of each other.

The gravitation force, that can be considered parallel distributed set of forces, acts on each element of the body. The center of parallel gravitational forces — the center of gravity —lies in the median sagittal plane; therefore, it also corresponds to the center line of gravityUnder normal conditions, the center line of

In case of a standing man, the center of gravity considered to be at the height of the 2nd sacral vertebra and 2 cm ventrally of it.

From the lateral view, the center line passes from the base of the cranium and crosses each load bearing joints of the body. The parts in front of and behind the center line are of equal mass that helps to keep the position of equilibrium.

In standing position the stability structurallyDetermined by the

physiological curvatures of the spine, inclination angle of the pelvis (sacrum) and

the sacroiliacal ligaments.

The spine rests on the pelvis through the sacrum. The pelvis transfers the weight of the trunk in the hip joints through the femoral head/neck to the lower extremities. In order to preserve the equilibrium, these points shall lie on a single straight line in the frontal plane.

 In order to ensure the equilibrium, the supporting point of the spine on the sacrum and the hip joints shall lie on a single vertical line in the frontal plane. To ensure this, the pelvic has to tilt forwards resulting in the lordosis of the lumbar spine.

Under normal condition the tilt of the pelvis - the aperture pelvis superior - forms an angle of 60 – 65 degrees with the horizontal plane.

The pelvis is a ring/shaped structure of double vault in the frontal plane. It has to ensure the distribution of single-point loading onto double-point support. The sacrum is the headstone of this vault.

The sacrum is a special headstone, because it`s wedge-shape facing upward.In spite of it does not "break" in the pelvis as the spine loads the sacrum not in the axle of the sacroiliac joint, but in front of and above it.

While functioning as a two-armed lever, the sacrum under load is nearly wedged in the pelvis with its coccygeal end. This makes the pelvis flexible and adaptable for the different loading.

What is the posture?  What is the right posture or what is called as a defect of posture?

According to convention, the vertical posture of human standing on two legs and being in equilibrium is termed as normal posture.

The normal posture is structurally determined; however, to maintain it requires active force of skeletal muscles that is either voluntary or the consequence of reflex mechanisms.

The condition of normal posture is the presence of physiological curves in the sagittal plane to a biological extent.

- Cervical lordosis 9 (2-24) degrees as an average,- N normal value of dorsal kyphosis 39 (22-56) degrees as an average,- Lumbar lordosis 41 (26-57) degrees.

„Negligent posture”

 If the posture deviating from the normal one can be corrected voluntarily totally, it is a negligent or incorrect posture.

The negligent posture is nothing else but weakness in the will for the right posture.This requires no treatment but only gymnastics.

What is the posture fault?

?

Might a child of nursery age have posture fault?

Would the medical gymnastics be necessary at the nursery?

Morbus Scheuermann  Juveniles osteochondrosis or osteochondritis, that means inflammation of the growing bony surfaces of the vertebral bodies.

That is the true, that histologically the juvenile osteochondrosis in the Latin terms means a sort of avascular necrosis followed by bony remodeling in the growth period, instead of inflammation. This can occur at any point of the body in puberty and the histological form is always the same without in account the affected region, but can cause serious deformities remaining for the adulthood in the hip and in the vertebral column.

The spine positioned in the back of the trunk. The body weight, or the weight of the trunk acting in front of it, exerts a rotating moment for the vertebral column. Due to the osteochondritis / osteochondrosis and the reduced mechanical strength the bending forces will damage the bony framework as the vertebrae become wedge narrowed towards ventral. The dorsal muscles are unable to balance the significant weight of the trunk. Its clear consequence is the "insufficientia vertebrae" as called by Schanz wherethe spine as a functional unit becomes insufficient.

In essentials, for the diagnose of Sheuermann disease the radiological appearance of Schmorl hernia is required

The Scheuermann-disease is hereditary. Its frequency is 11% in Hungary, without any difference according to sex.There is no relationship between complaint, appearance of dorsal pain and the severity of deformation. Therefore, especially in case of progressive type Scheuermann disease appearing in pre-puberty and beginning prior to the rapid growth period, significant deformity can develop nearly unnoticed. In such cases, the „negligent posture” or rather the posture seems to be negligent fixed; it cannot be corrected voluntarily, or even, permanent osseous deformity can be developed..

The etiology is unchanged; but its form of appearance seems to be modified in recent days.Commonly the clinical view of the Scheuermann disease means the increased thoracic kyphosis. However, there are also worse forms: the appearance of inverse physiological curves and the junctionalis kyphosis.

The junction is the meeting point or coming together of the kyphosis and the lordosis.

While in the Scheuermann disease of "classic" appearance the apex of the increased kyphosis is between T6-10, it is between the T11 and L1 in the case of junctionalis kyphosis.

The kyphosis is defined by its :

extent location (apex of the curve) type (regular or angular form)

What is the scoliosis?

Bending of the spine in the frontal plane is scoliosis.While the curves in the sagittal plane are physiologic – within a certain extent - and necessary, those in frontal plane are always pathologic ones.

Types of scoliosis can be:• functional scoliosis• congenital scoliosis• scoliosis of neuromuscular origin• scoliosis with neurofibromatosis • idiopathic structural scoliosis

Functional scoliosis is the bending of the spine in the frontal plane without any structural deformity of vertebral bodies.The frequency of primary functional scoliosis can reach as much as 15%. In the case of functional scoliosis there is no vertebral torsion, accompanied by rib prominence on the convexity. There is nevertheless significant and opposite directed tilt of the shoulder girdle and of the pelvis (PSIS cw or ccw) But however, prominence often seen at the concave side of the curve.

Tilt of the shoulders

Tilt of the shoulder girdle can be a part of the posture deformities can be seen in the different types of the scoliosis, but in itself, as a single sign is not characteristic for the scoliosis.

Causes forTilt of the pelvis

- intermittent leg-length difference (different rate of growth)

- different collodiaphyseal angle- deformities in axles of extremities (varus/valgus)- absolute leg-length difference- scoliosis

„Transitory process that will improve spontaneously.”(Glauber A.)

 „The permanent pathological curvature can be fixed

finally and can lead to severe complaints.” (Riskó T.) 

In the practice, the functional scoliotic curve is a long and moderate arc and affects nearly the whole spine.It is a static disturbance and can be corrected easily by leveling the pelvis. (Lifting the sole or the heel)

Congenital scoliosis It can result from development of unilateral wedge vertebras, hemi-vertebras or asymmetric block vertebras. Extra-vertebral causes might be the synostosis of ribs.Their treatment is mostly operative.

Paralytic scoliosis Usually the stabilization of the spine (external or internal) is required.

Scoliosis with Neurofribromatosis

Idiopathic structural scoliosis The structural scoliosis is genetically determined curve in the frontal plane due to the asymmetric growth of the vertebral bodies.  The scoliosis in addition to the 3D deformity of spine:

• disorganization of the posture,• disfunction of neuro-musculoskeletal system

and• disharmonic growth and maturation process.

The morbidity data of scoliosis are inaccurate as its frequency of occurrence is larger than the number of cases to be treated.Progrediting illness, its extent and rate are variable.

The scoliosis can often be associated with the irregular growth of teeth, (orthodontic problems) visual problems or irregularities in heart development (in fact, both of these organs take their origin from the embryonic mesoderm.)

The extent of the scoliotic curve is determined in Cobb degrees. It can be measured on the ap. or pa. X-ray. This is the projection of a 3D deformity on 2 planes.

XV

In structural scoliosis axial rotation exists not only between the individual vertebras, but also rotation between the two end-plate of the vertebral body, i.e. torsion is develop.

This structural difference is responsible for the clinically most apparent deformity, the asymmetric prominence visible on the one side of spine on bending forward. The prominence shown in the area of chest and ribs is the rib hump, rather called prominence. This is located at the side of convexity at the back and at the side of concavity in front.

The prominence measured by scoliometer and its extent expressed in degrees, or sometimes in cm.

In mechanical respect, the axial compression force further increases the structural scoliosis to an extent depending on the Cobb degree.

According to the Euler theorem well known in the mechanics, there exist a ratio of length and section above that value a column will be bent (buckle) irrespective of the force acting on it.The Euler theorem also tells that, in case a column once bended, this bend further increased by any axial force as the lever of force increases with the distance from the theoretical axle.

 

magasságmért h

szög Cobb

The loading moment : M = F .xwhere

A .h 2/sin*2

cos1h =x

Cobb szög ()

A

0 0

10 0,021

20 0,0437

30 0,0658

40 0,0881

In fact, this depends on two factors: the radius of curvature and the length of arc. According to calculations, the Cobb angle is the dominant factor; the force increases in proportion to the radius of curvature.

If a curved bar is under axial load, 60% of its section is under pressing force and 40% pulling force.

WHEN SHALL WE START THE TREATMENT OF THE SCOLIOSIS?

The idiopathic structural scoliosis begins between age 6 - 12, most frequently in pre-puberty, i.e. age 10 - 12. Although the view that all scoliosis became necessarily worse until the end of skeletal maturity is not justified, however, the progression also continues in case of young adults in 25 – 30% of cases.

If the Cobb angle increasing 2 to 3 degrees in every half year, the progression is moderate; if, however, the worsening exceeds 5 degree, the progression is clearly significant. Neither the speed of progression, nor the expected quantity of it can predicted safety, however: the relationship between the growth potential and the development of scoliosis is clear. The progression of scoliosis takes place at the beginning of puberty in the rapid growth period.

As earlier the scoliosis starts and as higher the growth potential, as larger is the progression.

• Lonstein and Carlson : – in the Risser 0-2 stage scoliosis of 20-

29 Cobb degree will progress in 68% in the rapid growth period.

• According to Stagnara : – if the scoliosis is above Cobb 30 degree

in the same stage, the expected progression is 100%. .

In 10% of the progressive cases, the worsening cannot be stopped of any conservative treatment; surgical treatment is necessary for them. On the other hand, in case of patients that do not reach 20 Cobb degrees until the beginning of rapid growth period, no substantial progression is available.

The most important types according to King-classification are:

In the breakdown of SpineCor System:

L Eu R EuL T / I.II.III. R T / I.II.III.L T „11” R T „11”L TL / I.II. R TL / I.II.LL RLLT-RL / I. III. RT –LL / I. III.

The apex of the curve is the structurally most destroyed vertebra.

In the SpineCor system, in order to obtain the classification of the scoliosis with accuracy, the evaluation combines a clinical exam, radiological and postural evaluation. The purpose of the postural geometry evaluation is to quantify non-invasively in 3-dimensions the position and orientation of pelvic girdle, shoulder girdle, spine and thorax. This evaluation provides a qualitative view of the patient in three planes. (Sagittal, frontal and transverse).

The postural geometry measured by means of the FreePoint device based on ultrasound propagation, and displayed by using a special software (SAS).

Especially in progressive cases, the disorganization of posture results in typical deformities.

SHALL THE SCOLIOSIS TO BE TREATED?

„By all means” „depending on”…

WHO SHALL TREAT THE SCOLIOSIS AND HOW?

- Health care provision? (Wither its task consists in treatment or just issuing certificates for the children?)

- The School?

- Swimming master?

- At home, using cassette?

In respect of the treatment of scoliosis, the orthopedic professional protocol in Hungary at present is as follows:

• 15-20 Cobb: physiotherapy• curve between 15-40 degrees: wearing brace• above 40 Cobb: surgery

WHAT IS THE PURPOSE OF THE TREATMENT ?

The purpose of treatment is to minimize the neuromusculo-skeletal dysfunction and the growth disharmony. Reduce or stabilize the scoliosis by means of reducing the postural disorganization and the spinal deformation.

Improvement of posture through the reduction of spinal deformities; development of a compensated, mobile spine maintaining the physiological curves that involves cosmetic results also acceptable to the patient

This is valid equally both for conservative (physiotherapy or brace) and surgical treatments and the transition between the three ones is continuous., Type of Braces:

- rigid braces of low profile (Cheneau, Boston, Stagnara)

- dual function (Charlston)- - dynamic (SpineCor, TriaC )

SCOLIOSIS CANNOT BE RESTORED TO HEALT, BUT CAN BE SUCCESSFULLY TREATED.

FOR CHILDREN, EVERY BRACE MEANS CONSTRAINT.

ANY BRACE CAN BE EFFICIENT JUST IF THE CHILD WEARS IT.

Operative treatment: 

• CD method• with fusion• without fusion