DEVIATIONS OF THE VERTEBRAL COLUMN
LORDOSIS--KYPHOSIS--SCOLIOSIS
Three main deviations of the vertebral column are described:
_Lordosis_, in which it is unduly arched forwards; _Kyphosis_, in
which it is unduly arched backwards; and _Scoliosis_ or lateral
deviations, in which the spine deviates to one side of the middle
line.
#Lordosis# or _anterior curvature of the spine_ with the convexity
forwards, is chiefly met with in the lumbar region as an exaggeration
of the natural curvature. A minor degree of lordosis sometimes occurs
as a peculiarity in the conformation of the individual and may be
present in several members of the same family; also in street-hawkers
and others who carry weights suspended in front of them; in very obese
persons; in those who suffer from large abdominal tumours, such as
fibroids; and in pregnant women. In its more marked and typical forms
it is met with as a compensatory deviation when the pelvis is tilted
forwards in association with flexion of one or of both hip-joints.
Illustrations of this association are found in congenital dislocation
of the hip, particularly when this is bilateral, in tuberculous
disease of the hip when recovery has occurred with ankylosis in the
flexed position, and in Charcot's disease of the hip. The resuming of
the erect position with tilting of the pelvis from flexion at the hip
is necessarily attended by an exaggeration of the forward curvature of
the lumbar spine. Its relationship to the erect posture is readily
demonstrated by noting its partial or complete disappearance when the
patient is sitting and the tilting of the pelvis is thus eliminated.
Lordosis elsewhere than in the lumbar segment is met with as a
compensatory deviation to kyphotic or backward curvature of the spine:
in Fig. 211, for example, a kyphotic projection in the mid-thoracic
region has led to a lordosis in the cervico-thoracic segment above,
and in the thoracico-lumbar segment below, the forward curve being
again a necessary outcome of the resuming of the erect posture. The
absence of a compensatory lordosis in such a condition would warrant
the inference that the patient had been bed-ridden.
#Kyphosis# or _posterior curvature of the spine_ with the convexity
backwards, is met with at all periods of life, and results from a wide
range of conditions.
In infancy it is a common result of _general debility_. The child need
not appear to be badly nourished, it may even be fat and look well,
but there is a want of muscular vigour such as should enable it to
hold itself erect in the sitting posture. It is to be noted that a
considerable degree of kyphosis may exist without interference with
the normal outlook in the erect posture, and, therefore, the question
of compensatory curvature does not arise. In the adolescent a degree
of kyphosis in the cervico-thoracic region is common, and is spoken of
as "round shoulders"; it is largely a matter of habit that requires
correction by the governess or nurse. Among agricultural labourers and
gardeners after middle life, and in the aged, this type of curvature
is of common occurrence and is evidently associated with their
occupation. An exaggerated form of the same cervico-thoracic kyphosis
is met with in patients suffering from progressive muscular atrophy,
poliomyelitis, osteitis deformans of Paget, acromegaly, and many
allied conditions in which either the muscular or the mental vigour is
deficient, and the patient adopts the cervico-thoracic kyphosis as the
attitude of rest.
Another type of diffuse kyphosis without compensatory curvature is met
with in _arthritis deformans_, in which the kyphosis is associated
with the disappearance of the intervertebral discs and ankylosis of
the vertebral bodies by bridges of new bone in the position of the
anterior common ligament.
_Partial or localised kyphosis_, on the other hand, is the result of
organic changes in the bodies of the vertebrae of the segment of spine
affected. It is most often met with in Pott's disease in which the
extent of the curve depends on the number of bodies affected, and its
degree on the amount of destruction that the bodies have undergone.
With the resumption of the erect posture, and in order that the eyes
should look directly forwards, a compensatory lordosis is acquired
above and below the segment that is the seat of kyphosis (Fig. 211). A
similar but less marked type of kyphosis may follow upon compression
fracture of the spine--in the condition known as traumatic
spondylitis; and as a result of other lesions, such as osteomalacia,
or malignant disease, in which the bodies undergo softening and yield,
so that the spinous processes project posteriorly.
SCOLIOSIS
#Scoliosis# or _lateral curvature_ is by far the commonest and most
important deviation of the spine. The student will obtain a clearer
conception of the nature of this deformity if we consider in the first
place those types for which an obvious explanation is available.
_Static scoliosis_, for example, when one leg is shorter than the
other, the pelvis is tilted down on the short side, the
thoracico-lumbar spine deviates laterally to the normal side, and to
restore the equilibrium of the trunk the cervico-thoracic spine
deviates again in the opposite direction. The causes of one leg being
shorter than the other are numerous and varied; they include such
conditions as unilateral congenital dislocation of the hip, fractures
united with overriding of the fragments, diseases of the joints,
_e.g._, hip disease, or of the bones, especially such as interfere
with the function of ossifying junctions; and acquired deformities
such as unilateral flat-foot, knock-knee, or bow-leg. Clinically,
this type of scoliosis is identified by observing that when the
patient sits down the deviation of the spine disappears; it is
relieved or got rid of by raising the sole and the heel of the boot on
the short side, and, if required, by inserting an "elevator" inside
the boot.
When there is _shortening of the muscles on one side of the trunk_
there develops a lateral curvature of the spine with its convexity to
the normal side; a good example of this is afforded in cases of
infantile hemiplegia (Fig. 224) in which the deviation affects the
entire column: a localised form is seen in congenital wry-neck, in
which the convexity of the cervico-dorsal curve is on the side of the
normal sterno-mastoid with a compensatory deviation to the opposite
side in the spine below (Fig. 272). _Unilateral paralysis_ of
_muscles_ acting on the trunk may also cause a lateral deviation of
the spine, as is well seen in paralysis of the trapezius, which
results in a cervical scoliosis with the convexity to the
non-paralysed side.
[Illustration: FIG. 224.--Scoliosis following upon Poliomyelitis
affecting right arm and leg.
(Mr. D. M. Greig's case.)]
_Asymmetry of the thorax_, such as may follow on empyema with
defective expansion of the lung, causes a lateral deviation of the
dorsal spine with the convexity towards the normal side.
_Attitudes_ adopted to relieve pain, such as that caused by sciatica,
sacro-iliac or hip disease, in which the weight of the body is
transferred to the normal side, cause a scoliosis similar to that due
to irregularity in the length of the lower extremities, and is
similarly made to disappear when the patient sits upon a flat surface.
_Malformation_ or _disease of the vertebrae_ themselves is a well
recognised cause of scoliosis; the best known, as it may be also the
most severe and the most intractable, is that due to rickets, under
which heading it has already been described (Fig. 225). In a few cases
a rudimentary wedge-shaped vertebra has been revealed by the X-rays.
[Illustration: FIG. 225.--Rickety Scoliosis in a child aet. 2.]
In all of these forms or types of scoliosis the primary cause must be
searched for and when found is made the first object of treatment; the
treatment of the scoliosis as such is on the same lines as in the
postural variety that now falls to be described.
#Habitual or Postural Scoliosis.#--These names have been given to the
type of scoliosis that develops in young girls and for which there is
no mechanical explanation.
It is most frequently met with in rapidly growing girls of poor
physique who are overworked at school or lessons, or on commencing an
apprenticeship for which they are physically unfit. In some cases
there is nasal obstruction from adenoids, in others the development
and free play of the chest are interfered with by tight and
ill-fitting garments; in all of them the muscular system is weak and
the muscles of the trunk do not take their proper share in maintaining
the erect posture. The most important determining factor would appear
to be the habitual or repeated assumption of faulty attitudes, partly
from carelessness, largely from fatigue, in order to relieve the
feeling of tiredness in the back. So far as is known, the condition
does not occur in communities living under aboriginal conditions. In
some cases there is a hereditary tendency to scoliosis; we have seen
it, for example, in a father and his daughters.
The excessive use of one arm in the carrying of weights, the habit of
resting on one leg more than the other, or the assumption of a faulty
attitude in writing or in playing the piano or violin, doubtless,
determine the seat and direction of the curvature, and, when it has
once commenced, tend to aggravate and to perpetuate it.
It is probable that the greater frequency of the primary curvature
towards the right is associated with the more general use of the right
hand and arm, although primary curvatures towards the left are not
confined to left-handed persons.
_Morbid Anatomy._--The original deviation or "primary curve" is
usually in the thoracic region, and has its convexity directed towards
the right side. To re-establish the equilibrium of the column,
"secondary" or "compensatory" curves, with their convexities to the
left, develop in the regions above and below the primary curve. It has
been proved experimentally that lateral deviation of the spine is
inevitably accompanied by rotation of the vertebrae around a vertical
axis, in such a way that their bodies look towards the convexity of
the curve, while their spines, laminae, and articular processes are
directed towards the concavity (Fig. 226).
[Illustration: FIG. 226.--Vertebrae from case of Scoliosis, showing
alteration in shape of bones.]
As the deformity increases, the individual vertebrae are distorted, the
bodies becoming wedge-shaped from side to side, the base of the wedge
looking towards the convexity of the curve, while the narrow end looks
towards the concavity (Fig. 228). As the spine, laminae, and articular
processes also undergo alterations in shape, a line uniting the tips
of the spinous processes does not furnish an accurate index of the
degree of lateral deviation but minimises it considerably. The muscles
and ligaments are altered in length in accordance with the changes in
the shape and position of the bones.
In the thoracic region, the ribs necessarily accompany the transverse
processes, so that on the side of the convexity they form an undue
prominence behind--the "rib-hump" (Fig. 227), while on the side of the
concavity the chest is flattened and the ribs crowded together so that
the intercostal spaces are diminished or even obliterated. The
converse--flattening on the side of the concavity--is seen on the
front of the chest.
[Illustration: FIG. 227.--Adolescent Scoliosis in a girl aet. 23.]
The general shape of the thorax is altered: on the side of the
convexity it is longer and narrower than normal and its capacity
diminished, while on the side of the concavity it is shorter and
broader and its capacity is increased.
The viscera are distorted and displaced in accordance with the altered
shape of the thoracic and abdominal cavities. The twisting of the
spine causes the patient to lose in stature, and the limbs appear to
be disproportionately long. In advanced cases the pelvis becomes
obliquely contracted--a deformity known as the _scoliotic pelvis_.
[Illustration: FIG. 228.--Scoliosis with primary curve in Thoracic
Region.]
In spite of the marked deformity the spinal cord is never compressed.
_Clinical features._--The development of scoliosis is always slow and
insidious. As a rule, attention is first attracted to the deformity
about the age of puberty, but in most cases it has existed for a
considerable time before it is observed. The patient--usually a girl,
although it also occurs in boys--is easily fatigued, has difficulty in
keeping herself erect, and often complains of pain in the back and
shoulders and along the intercostal spaces on the side of the
convexity. To relieve the muscles of the back she is inclined to
lounge in easy and ungainly attitudes.
The most common form of scoliosis met with in adolescents is a
_primary thoracic curvature_ with its convexity to the right (Fig.
227), and with more or less marked compensatory curves towards the
left in the lumbar and cervical regions. The thoracic spines lie
towards the right of the middle line. On account of the prominence of
the ribs, the right scapula is projected backwards, and its inferior
angle is on a higher level and farther from the middle line than that
of the left scapula. The right shoulder seems higher than the left,
and is popularly said to be "growing out"--a point which is often
first observed by the dressmaker. The right side of the back is unduly
prominent, while the left side is flattened. A deep sulcus forms in
the left flank below the costal margin, and the space between the arm
and the chest wall--the "brachio-thoracic triangle"--on the left side
is much more marked than on the right; and the left iliac crest
usually projects upwards and backwards. As seen from the front, the
right side of the chest is flattened, while the left side is
abnormally prominent, the breasts are asymmetrical, and the right
nipple is on a higher level than the left.
[Illustration: FIG. 229.--Scoliosis showing rotation of bodies of
vertebrae, and widening of intercostal spaces on side of convexity.]
In aggravated cases, the patient may suffer from shortness of breath
on exertion, and the respiratory difficulty may react on the heart,
causing dilatation of the right side, palpitation, and precordial
pain.
Sometimes, and particularly in males, the primary curvature is in the
lumbar region, and the convexity is to the left. The deviation of the
lumbar vertebrae produces a prominence in the left flank which masks
the outline of the iliac crest on that side, while the right flank
shows a deep furrow and the right half of the pelvis is unduly
prominent. There is a slight compensatory curve to the right in the
thoracic region, and the right side of the chest projects backwards.
The brachio-thoracic triangle is much more marked on the right than on
the left side.
_Diagnosis of Adolescent Scoliosis._--In many cases the patient is
brought to the surgeon on account of pain and weakness in the back
before any distinct deviation has developed, and, unless a careful
examination is made, the real cause of the symptoms is liable to be
overlooked.
The patient should be stripped and examined in a good light in various
attitudes; for example, standing in an easy position, standing as
straight as she can, and sitting on a flat stool. She should also be
asked to read from a book and to write, in order to exhibit her usual
attitudes. In early cases, an inequality in the level of the angles of
the scapulae is often the only physical sign to be detected. It should
also be observed whether the line of the spines is altered when the
patient hangs from a horizontal bar or trapeze. Any backward
projection of the ribs on one side is rendered more obvious if the
patient folds the arms across the chest and bends well forward, while
the surgeon looks along the back from behind.
Pott's disease may be excluded by the absence of rigidity. Any
mechanical cause of deviation of the spine, such, for example, as
inequality in the length of the limbs or contraction of the chest
after empyema, must be sought for. Scoliosis that depends upon
inequality in the length of the limbs or tilting of the pelvis,
disappears on sitting.
_Treatment._--The treatment of postural scoliosis implies a
comprehensive programme, including attention to the general health,
habits, and exercises out of doors and in the gymnasium, clothing,
etc., all requiring supervision over a period of months, or even of
years. The object of the treatment is to correct the deformity before
the position has become fixed by rotation of the vertebrae and
alteration in their shape. The child must not be allowed to assume
awkward attitudes while reading, writing, or playing the piano; she
must sit on a low chair, the seat of which slopes slightly downwards
and backwards, and the back rest of which reaches as high as the
shoulders, and is at an angle of 100 deg.-110 deg. with the seat. The feet
should rest on a sloping stool, and when the child is reading or
writing, a desk sloping at an angle of 45 deg. should be used. In weakly
girls approaching the period of puberty, special care should be taken
to avoid compression of the trunk by tight corsets. Adenoids or other
sources of respiratory obstruction must be removed; and if the patient
is myopic she should be provided with suitable glasses. Standing
should be avoided, as there is a great tendency to throw the weight on
to one leg; but walking, running, and other exercises which bring both
sides of the body into action equally are permitted under supervision.
Horse-riding is a suitable form of exercise, but girls must ride
astride; cycling is not to be recommended.
In mild cases--that is, those in which the curvature is obliterated
when the patient is suspended--the prophylactic measures above
mentioned must be rigidly enforced, and gymnastic exercises should be
prescribed. The exercises should not be commenced, however, until,
after a period of rest in bed, all pain and feeling of tiredness in
the back have disappeared.
In cases in which the curvature is not affected by suspension, the
deformity is usually permanent, but by suitable exercises it may be
prevented from becoming worse, and the patient may be educated to
disguise it to a considerable extent. Training is also directed
towards _regaining the muscular sense_; with the eyes shut before a
mirror, the child should endeavour to assume the correct posture; on
opening the eyes, the faulty attitude is seen and corrected. Forcible
correction by means of successive plaster jackets, applied in _the
flexed position_, somewhat on the lines employed by Calot in Pott's
disease, has yielded results which may be described as encouraging.
Only in very advanced cases should the patient be allowed to wear a
supporting jacket; such appliances have no curative effect, and can
only be expected to relieve symptoms.
* * * * *
_Exercises for Lateral Curvature._--The particular exercises given
must be carefully selected to meet the indications present in each
case, the movements prescribed being designed to strengthen the weak
muscles and ligaments, to increase the mobility of the spine as a
whole, and to correct the deviation that exists. The exercises should
be taken twice daily, preferably in the morning and afternoon, and
after each spell the patient should rest for an hour, lying flat on
the back. During the exercises the breathing should be carefully
regulated, and at the end of each movement one or two deep breaths
should be taken. Each movement should be carried out slowly, the
number of times it is repeated varying from four to twelve or more,
according to the nature of the exercise and the strength of the
patient. The exercises should be stopped if the patient feels
fatigued. Hot-air baths and massage are useful adjuvants to all forms
of exercise.
#Special Exercises for Thoracic Curvature with convexity to
right.#--1. _Stand_ with arms by side; palms directed forward;
shoulders braced back. This is referred to as the "_best standing
position_" or _original position_. 2. Slowly raise arms from sides
until level with shoulders, with palms directed forward; carry left
arm straight upward--"_the keynote position_." Then slowly lower left
arm to level of shoulder; lower both arms into original position. 3.
_Assume keynote position_: slowly bend body forwards at hips until
stooping position is reached, with legs kept quite straight, head bent
slightly backwards, and eyes directed forward. Gradually return to
keynote and original positions. 4. _Keynote position_: slowly bend
whole spine to right; resume keynote and original positions. 5.
_Keynote position_: turn body forward sideways. 6. _Keynote position_:
rise on to balls of toes. 7. _Keynote position_: rise on to balls of
toes; bend knees; back to original position in reverse order. 8.
_Patient suspended from bar or rings, the left end of the bar or left
ring being three inches higher than the right._ (_a_) Draw right knee
upwards and forwards against resistance. (_b_) Draw legs apart against
resistance. (_c_) Draw legs together against resistance. 9. _Patient
lying on back._ (_a_) Bend right knee- and hip-joints against
resistance. (_b_) Extend right knee and hip against resistance. (_c_)
Rotate right hip against resistance. 10. _Patient lying on face with
pillow under chest_; slowly raise arms to keynote position. While
limbs are firmly held by a nurse, raise the body backwards and to the
right. 11. _Same position_: make swimming movements. 12. _Patient
astride a narrow table or chair, without a back._ (_a_) Repeat
exercises 3, 4, 5, and 11. (_b_) Bend body forwards, backwards; and
rotate to right and left against slight resistance made by nurse
grasping patient's shoulders.
_Klapp's "four-footed" Exercises._--Rudolf Klapp has devised a series
of exercises designed to strengthen the muscles and ligaments of the
spine, and to increase the mobility of the column. To take the weight
of the body off the spine, and to render both ends of the column
mobile, these exercises are carried out in the "all-fours" attitude,
the patient crawling in imitation of a quadruped, that is, in such a
way that the hand and knee of one side are approximated, while those
of the other side are separated; in other words, the hand and knee of
one side should not move forward simultaneously (Fig. 230). With each
step the spine is curved laterally, the concavity of the curve being
towards the side on which the hand and knee are approximated. The
exercises, for a case of dorsal curvature with the convexity to the
right, for example, are graduated as follows: (1) The child crawls in
a straight line till he has acquired the "quadruped gait"; (2) with
each step forward the head is inclined towards the side on which the
hand and knee are approximated; (3) at each step the hand and knee
which are wide apart are brought over and cross the limbs on the other
side; (4) to open out the concave left side, he crawls in a circle
towards the right. The exercises are practised morning and afternoon
for from fifteen to sixty minutes at a time. If there is a marked
_double_ curve, it is best neutralised by imitating the "pacing"
action of a quadruped, _i.e._, the limbs of the same side moving
forward together. The hands, knees, and toes should be protected by
suitable gloves and leather pads. Hot-air baths and massage are useful
adjuvants to the exercises.
[Illustration: FIG. 230.--Diagram of attitudes in Klapp's four-footed
exercises for Scoliosis.]
Abbott has introduced a method of treatment applicable to cases in
which the deformity has become permanent. Under general anaesthesia,
the patient being slung in a bracket-frame with the spine flexed, the
curvature is over-corrected and a plaster-case is then applied to
maintain the attitude; the plaster-case is renewed at intervals of two
or three months.