Congenital Scoliosis

　　Like other congenital malformations, the cause of congenital scoliosis is not clear. Most scholars believe it is caused by abnormal embryonic development, and the relationship with heredity is not yet clear. Scoliosis is classified according to the type of deformity, mainly divided into formation disorders, segmentation disorders, and mixed deformities.

　　1. Postural scoliosis:Often caused by some incorrect posture, commonly found in school-age children. This type of scoliotic deformity is not severe, and the deformity can disappear automatically when the patient lies flat or hangs by one hand on the horizontal bar.

　　2. Neurological scoliosis:Caused by unbalanced muscle tension due to poliomyelitis, neurofibromatosis, syringomyelia, cerebral palsy, etc., the younger the onset age, the more severe the scoliotic deformity.

　　3. Pathological scoliosis of the chest:Young children with purulent or tuberculous pleurisy may have thickened pleura and contracture; or in the pediatric period, thoracoplasty may be performed, disturbing the balance of the spine during development, which can also cause scoliosis.

　　4. Malnutrition-induced scoliosis:Children with rickets caused by vitamin D deficiency may also have scoliosis.

　　In addition, in intervertebral disc herniation, nerve roots may be stimulated or compressed; in peripneumonic inflammation, one side of the muscle may spasm, and uneven length of the two lower limbs may be caused by various reasons, which can lead to functional scoliosis. Fracture dislocation or spinal tuberculosis can also cause scoliosis.

　　1. Scoliosis is classified according to the type of deformity, mainly divided into formation disorders, segmentation disorders, and mixed deformities. The most typical example of formation disorder is hemivertebra; typical segmentation disorder is bone bridge, which refers to the bony connection on one or both sides of two or more vertebrae; mixed type refers to the presence of both of the above two deformities in the same patient.

　　1. Secondary chest deformities caused by scoliosis can lead to a reduction in the volume of the chest and abdomen, resulting in visceral dysfunction. For example, the heart may be displaced to some extent, heart rate may increase, lung capacity may decrease, there may be indigestion, and loss of appetite; on the convex side, nerve roots can cause traction symptoms, on the concave side, they can cause compressive symptoms, stimulation of nerve roots can cause radiating pain in the chest and abdomen; there may also be cases of spinal cord dysfunction. Due to visceral dysfunction, patients often have poor overall development, short stature, weak physical strength, and poor cardiopulmonary reserve.

　　In addition, parents discovering it early is an effective measure to prevent further harm from the disease. Key points of identification: Since patients with scoliosis do not feel pain or itching and have no symptoms, it is often difficult to detect early if parents are not paying enough attention.

      There are several methods that can help in the early detection:

　　1. Pay attention to whether the child's back is symmetrical and whether there is any local swelling during bathing. If there is any suspicion, let the child bend forward, keep the knees straight, and stand on the opposite side of the child. If there is asymmetry, it should be checked with an X-ray at the hospital.

　　2. Check if there are any abnormal hair, spots, or tumor-like protrusions on the skin. Abnormal hair often indicates the presence of spinal defects and other malformations, while spots or multiple subcutaneous masses may indicate the possibility of neurofibromatosis.

　　3. Check if the child has an abnormal gait, and if so, check if the pelvis is level. Since the onset age of different scoliosis is different, regular check-ups for children should be carried out to avoid delays in diagnosis and treatment.

　　During the examination, the infant is suspended from under the armpit to observe the rigidity and flexibility of the curvature, perform a neurological examination, check for increased or decreased muscle tone, understand the presence of other congenital malformations, take suspended position and supine full-length anteroposterior and lateral X-ray films of the spine, and observe the Cobb angle, Mehta sign, and rib vertebral angle differences.

　　For obvious scoliosis, a general physical examination can determine the diagnosis, but for the angle of curvature, it still needs to be finally determined by X-ray photography.

　　The diet of patients with congenital scoliosis should be light and easy to digest, with an emphasis on eating more vegetables and fruits, and a reasonable diet should be maintained, with attention to adequate nutrition. In addition, patients should also pay attention to avoiding spicy, greasy, and cold foods.

　　Treatment measures

　　Many factors affect the treatment of congenital scoliosis, such as patient age, gender, site of deformity, degree of curvature, segment length, type of deformity, flexibility, and progression, all of which are of great significance. Doctors should choose different treatment methods according to different situations.

　　1. Non-surgical treatment

　　Extensive experience has proven that congenital scoliosis is different from idiopathic scoliosis, and it is ineffective for gymnastics therapy, physical therapy, exercise therapy, and electrical stimulation therapy. The Risser plaster correction therapy, due to the weight of the plaster, often has complications such as pressure sores, chest deformity, and reduced lung function, and this therapy has been abandoned or used less frequently. Therefore, in the non-surgical treatment of congenital scoliosis, the main treatment is brace therapy, and a brief description of the indications and efficacy of brace treatment will be provided. Although brace therapy is the main or only non-surgical treatment method for congenital scoliosis, not all congenital scoliosis is suitable for brace treatment. Its indications are limited, and patients with immature development, gradually worsening deformity, long and flexible segments of curvature are suitable for brace treatment. Braces are not needed for patients without progression, and they are not suitable for cases where the deformity has spontaneously improved. For cases with short and rigid segments, brace treatment is almost ineffective. Flexibility plays an important role in treatment selection, so before treatment, the degree of flexibility is checked through upright, supine, traction, or lateral flexion positions to understand the degree of flexibility. Winter believes: if the scoliosis is less than 50° and the flexibility is greater than 50%, the general brace treatment effect is good. If the scoliosis is between 50° and 75°, and the flexibility is between 25% and 50%, brace treatment may be beneficial. However, for those with a scoliosis greater than 75° and flexibility less than 25%, brace treatment is almost ineffective.

　　There are two common types of braces:

　　1. The Milwaukee brace is also known as the cervical-thoracic-lumbar-sacral orthosis (CTLSO) (Figure 1). It is suitable for treating cervical-thoracic and thoracic scoliosis. For cervical-thoracic scoliosis, a shoulder ring can be used, and a support pad is added on the side of the head, applying a downward and inward pressure on the convex side of the shoulder and upper thoracic segment, and an opposing lateral force is applied on the higher plane on the opposite side. For upper thoracic scoliosis, a support pad on the side of the head is not required, only a shoulder ring, or a trapezius muscle pad. For middle thoracic scoliosis, a standard thoracic pad is applied on the convex side. If the patient also has another primary or secondary lumbar scoliosis, a lumbar pad should be added. (1. Neck collar 2. Rod 3. Belt 4. Neck collar clip 5. Belt 6. Lumbar support 7. Neck brace 8. Rod 9. Back support)

　　2. Thoracolumbosacral orthosis (TLSO) The thoracolumbosacral orthosis is suitable for the thoracolumbar segment and below. For congenital scoliosis with the apex vertebra at T10 or higher levels, the Milwaukee brace is used. For scoliosis with the apex vertebra in the thoracolumbar segment, a corrective force is added on the convex side of the thoracolumbar segment, and an opposing force is placed on the opposite side at the upper horizontal level. For scoliosis with the apex vertebra in the lumbar segment, no opposing force is applied at the axilla, but at the lower part of the chest. Figure 2 The TLSO brace treatment is a long and difficult treatment method that requires cooperation from both parents and patients. It is required that the patient wear the brace full-time, with only one hour allowed to remove it per day, and it is not allowed to wear it intermittently, for part of the time, or seasonally. The wearing time continues until maturity and vertical growth stops. After Risser sign 4 (degree), it usually takes 2 years to stop wearing the brace, with the first year transitioning from full-time wear during the day to wearing it only at night, and the second year being completely worn at night. Premature and rapid discontinuation of the brace can cause the scoliosis to worsen.

　　Secondly, surgical treatment

　　It is impossible to solve congenital scoliosis of different ages, types, and conditions with a single surgical method. It is necessary to analyze the specific situation and select the treatment method.

　　1. Simple Spinal Fusion Surgery

　　The main purpose is not to correct the scoliosis, but to stabilize the spine and prevent further progression of the scoliosis. Especially for those rigid types, brace correction is ineffective, and the scoliosis is worsening, simple posterior fusion should be performed. For unilateral non-segmented scoliosis, do not fuse too many non-segmented movable units, and the amount of bone grafting should be sufficient. It is best to use autologous bone grafting, and if it is difficult to take iliac bone in young patients, allogeneic bone can also be used.

　　2.石膏矫正下后路融合术

　　Applicable to those with a young age (under 9 years old), difficult to perform instrument correction, and flexible and progressive scoliosis.

　　3. Postoperative Instrumental Fixation and Fusion After Traction Correction Congenital Scoliosis, preoperative slow and long-term traction can avoid a sudden correction and traction during a single operation, which is of great significance in preventing spinal cord nerve complications and increasing the rate of surgical correction. Gradually increase the traction amount before surgery to understand whether the patient has changes such as numbness, pain, muscle tension, muscle strength, and reflexes. After achieving a satisfactory correction degree, perform instrumental fixation and bone graft fusion surgery. Spinal cord myelography is required before surgery to exclude any abnormalities in the spinal canal. Spinal cord electrophysiological monitoring should be performed during surgery, and an awakening test should be conducted at the same time. Common orthopedic fixators include Harrington and Luque instruments. However, sometimes due to the lack of lamina space in congenital scoliosis, Luque's pedicle wire crossing is difficult, and it is not as good as the expansion performance of Harrington instruments, so Luque instruments are rarely used alone and are often used in combination with Harrington instruments.

　　4. Epiphysis Blocking Surgery

　　The principle is to destroy the epiphysis on the convex side, making it fuse, blocking the excessive growth on the convex side, while retaining the凹侧epiphysis, allowing the凹侧growth. Generally, the anterior and posterior approaches are taken to fuse the epiphysis of the half vertebral body and the small joints. This operation is suitable for children and not suitable for nearly mature patients or kyphotic patients.

　　5. Hemivertebra Excision or Osteotomy

　　Applicable to patients with rigid angulated deformities, the surgical effect is better when the secondary curvature has not yet developed into a structural curvature.