DegenerativeScoliosis退变性脊柱侧凸

Degenerative Scoliosis,Wang Xuepeng M.D.Hangzhou First Peoples Hospital,Epidemiology,can be differentiated into two major groups, i.e., primary degenerative scoliosis or de novo scoliosis and secondary degeneration of adult idiopathic scoliosisthe prevalence of scoliosis in patients older than 50 years is about 6%,the average age of those seeking medical care is in the sixties.there is a potential for curve progression with an average of 3.3 one year,Pathogenesis,the asymmetric degeneration of the disc and the facet joint leads to an asymmetric loading of the spinal segment and consequently an asymmetric deformity, i.e., scoliosis or kyphosisthe formation of osteophytes at the facet joint (spondylarthritis) and at the vertebral endplates (spondylosis) contributes to the increasing narrowing of the spinal canal together with the hypertrophy and calcification of the ligamentum flavumand joint capsules, creating central and recessal spinal stenosis,Classification,the classification of Lenkes may be able to cover the adult idiopathic scoliosis group with secondary degeneration but is not necessarily adequate for the primary degenerative scoliosis type,Classification,Schwab distinguished three groups based on measurements of the endplate obliquity of L3 in the frontal plane, and of the lumbar lordosis measured between the L1 and S1 superior endplates in the sagittal plane,Classification,Cardinal Symptoms,Back Painis the most frequent clinical problem of adult scoliosispatients often complain of axial back pain due to segmental instabilityat the site of the curve can be localized either at the apex or in its concavityunbalanced, overloaded and stressed paravertebral back muscles may become very sore and in return will not contribute to balance, consequently becoming part of a vicious circle,Spinal Claudicationis the second most important symptom of adult degenerative scoliosis and may express itself as: radicular claudication central claudicationthe roots are compressed not necessarily on the concave side due to a narrow foramen, but often on the convex side,Neurological Compromiseneurological deficits occur lateis the third most important clinical presentation and may include individual roots, several roots or the whole cauda equina with apparent bladder and rectal sphincter problems,Increasing Deformityosteoporosis accelerates curve progressionlarger curves tend to progress faster than small curves for biomechanical reasons,Physical Findings,Standard Radiographs,full body standing radiographs are indispensableradiographs sometimes exhibit clues to the etiology of the curve (primary vs. secondary)important to look at earlier radiographs to understand the natural history and therefore the etiology of the curve,Magnetic Resonance Imaging,is the imaging modality of choice to explore neural compromise and disc degeneration,Computed Tomography,computed tomography with or without a myelogram is the diagnostic imagingmethod of choice in the case of diagnostic uncertainties related to the three dimensional,Interventional Radiological Procedure,in the context of the evaluation of the pain source, spinal injection studies are especially helpful since their findings may change the therapeutic approach,Additional Diagnostic Tools,temporary immobilization cast in the form of a thoracolumbar orthosis (TLO) or thoracolumbosacral orthosis (TLSO) to see whether an overall stabilization and fusion of the whole scoliotic spinal area could be beneficialneurophysiologic studies may be helpful to identify the responsible levelosteodensitometry (DEXA) is indicated whenever there is a suspicion of osteoporosis because of the implications with regard to curve progression and potential spinal fixation,Non-operative Treatment,The non-surgical treatment options basically consist of: non-steroid anti-inflammatory drugs (NSAIDs) muscular relaxation pain medication muscle exercises gentle traction (in selected cases) spinal injection studies orthosis,Non-operative Treatment,manipulations and physical activation should be avoided because they may increase the paintherapeutic epidural and selective nerve root blocks as well as facet joint blocksmay help to control the pain temporarily. a well-fitted brace to support the painful spine area may be necessary,Operative Treatment,Correction Procedures,whether or not a degenerative scoliosis should be corrected remains a crucial and complex question.the treatment of a degenerative scoliosis has different goals than the treatment of adolescent scoliosis. It depends on several factors:,Correction Procedures,Sagittal balance is most important,Surgical Techniques,debate continues on the indications for a lumbosacral fusion in young patients with secondary degenerative scoliosis, it is better to omit L5/S1 from fusion whenever possible in order to prevent iliosacral joint degeneration