prof. Dr. Halil İbrahim Secer
Brain and Nerve Surgery (Neurosurgery)
The human spine is not perfectly straight when viewed from the side. There is a slight depression (lordosis) in the neck and waist area and a slight hump (kyphosis) in the back area. When viewed from behind, it should be perfectly straight. Scoliosis (curvature of the spine) refers to the curvature of the spine to the right or left.
Scoliosis is actually a finding, not a disease. Just as symptoms such as fever or pain can occur due to different diseases, various diseases can also cause scoliosis. Therefore, scoliosis can be defined as a formal deformity that occurs in a healthy spine structure.
Scoliosis can occur due to many diseases, as well as at different ages and in various parts of the spine structure. Scoliosis, which occurs for the same reason in two different people, does not show the same course. Scoliosis has unique treatment methods that vary from person to person.
Frequency of scoliosis
Scoliosis is seen in approximately 2-4% of the society. Most of these are low-grade curvatures. It can be seen 8-10 times more frequently in girls than boys. In only 10 percent of people with a curvature of the spine, the scoliosis progresses to a degree that requires treatment. Regular exercise, keeping the back muscles strong, increasing the condition and being more fit are indispensable elements in almost every step of scoliosis follow-up and treatment.
Types of scoliosis:
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Idiopathic scoliosis (scoliosis of unknown cause)
It is the most common type of scoliosis. It is 'idiopathic' scoliosis, the cause of which has not been fully elucidated. The lateral bending of the spine can be 'S' or 'C' shaped. Apart from lateral bending, rotation of the vertebrae is also seen in all idiopathic scoliosis, including the mildest forms. This rotation in the vertebrae causes asymmetric protrusions in the back or waist.
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neuromuscular scoliosis
The second most common type of scoliosis is neuromuscular scoliosis. Muscle or nerve diseases may be among the main causes of neuromuscular scoliosis. Nervous diseases can originate from the brain and spinal cord; Muscle diseases can be seen in childhood and later. In neuromuscular scoliosis, unlike idiopathic scoliosis, respiratory distress and sensory deficits may be more common. Scoliosis brace may not be used during the treatment process due to reasons such as respiratory problems, communication disorders, sensory defects and epileptic seizures. In this type of scoliosis, younger ages may be preferred for surgical intervention. Fusion therapy can be applied.
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Congenital scoliosis
Congenital scoliosis is the third most common. It is a type of scoliosis due to spinal anomalies that occur during the development of the child in the mother's womb. Congenital scoliosis progresses rapidly in the first years. For this reason, the treatment process of congenital scoliosis that occurs in the early stages may require surgical intervention at a young age.
Apart from these, neurofibromatosis, various rheumatic diseases, various connective tissue diseases such as osteogenesis imperfecta, Marfan syndrome, Ehler Dsanlos, spinal fractures, spinal infections, various metabolic diseases such as Morquio, Gaucher disease and some genetic syndromic diseases may cause scoliosis.
Treatment of scoliosis:
The treatment process of scoliosis varies according to the disease causing the scoliosis and the scoliosis that occurs in the person. In other words, while the treatment process continues in its natural course for some patients; In some patients, the response of the person to treatment may vary depending on the type of scoliosis. Scoliosis progresses with growth during childhood and adolescence. That is, the curvature of the spine increases even more.
For all these reasons, there is no single correct treatment option for scoliosis that can be applied to all situations. The age at which the scoliosis was diagnosed, the location and degree of the curvature, the causes of the scoliosis, the examination findings and the data obtained from the radiological examinations, that is, the treatment to be 'personalized' for scoliosis should be applied meticulously, varying from patient to patient.
Although each treatment option varies according to the patient, there are generally three alternative ways after the diagnosis of scoliosis.
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The first option is follow-up and is suitable for curvatures less than 20-25 degrees and consists of following up at certain intervals, increasing sports activities and general body condition. Physical therapy exercises specific to scoliosis may be beneficial. But timing is important for these exercises. Exercises started at a very early age can cause early boredom in the child. As a result, the child may not want to exercise at an advanced age when exercise may be essential and rapid growth occurs.
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The second option is corset treatment. It is a method that is effective in people whose curvature is between 20-40 degrees and has growth potential. In other words, those who use corsets are less likely to have surgery. Wearing the corset for 20-23 hours a day was found to be important in terms of effectiveness.
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Another option is surgical treatment. Surgery generally comes to the fore in curvatures above 40-45 degrees. Correction and freezing (fixing) operations are performed in adolescents and adults whose lung development is completed. Preoperative preparation and planning are important in order to achieve maximum improvement by operating at the lowest level possible, as movement limitation will be made in the vertebrae included in the surgery.
Innovations in scoliosis treatment
Freezing surgeries should be avoided in children under the age of 10 with scoliosis, as they will prevent growth and lung development. The classical surgical method in children is to extend the sticks placed on the spine every 6 months without freezing. In this classical method, rods were placed in the body and lengthening was achieved with repetitive surgeries at 6-month intervals. The stress, complications and economic burden caused by these surgeries on patients and their relatives have led doctors to seek other solutions. By using the magnetic rods invented at the end of these studies, elongation can be performed without surgery and painlessly with a remote control every 2-3 months in outpatient clinic conditions.
SAn important concern in the surgical treatment of lichen is the risk of paralysis of patients during surgery. The effects of previous interventions on the spinal cord could not be seen, but when the patients were awakened towards the end of the surgery, it could be understood whether they were paralyzed or not. Although this procedure was troublesome for the patient, the intervention was delayed because it was understood at the end of the operation.
Neuromonitoring, which continuously displays the functions of the nerves during surgery, came to our country 4-5 years ago and is now widely used. Thus, the effect of any procedure that may cause nerve injury during the operation is immediately understood and the necessary intervention is performed. The neuromonitorization technique has significantly increased the safety of these surgeries, which may have resulted in paralysis from time to time, and has enabled operations that could not be performed for fear of paralysis to be performed easily today. Thanks to this technique, complicated curvatures can now be corrected.
One of the most important problems related to scoliosis surgeries is the fixation of the spine and the elimination of spinal mobility in a certain part. The work of spine surgeons on a correction technique that will allow the spine to grow and remain mobile without freezing has slowly started to bear fruit.
A method called the “stretching method” has been developed for patients with scoliosis in the spine who still have growth potential. In this method, screws are placed on the convex side of the dorsal curvature by endoscopic intervention from the side and these screws are tied with a thick thread and stretched to provide some improvement and the convex side of the curvature is prevented from growing. Thus, while the concave side continues to grow, the growth of the convex side stops thanks to the thread attached to the screws, and the curvature self-corrects over time. However, this technique has not yet become widespread.
The word congenital means that it is present from birth and that the problem occurs while in the mother's womb. Deformity is a structural deformity. In other words, the term congenital spinal deformity refers to the deformities of the spine that occur while in the womb and progress with age cc781905-5cde-3194-bb3b-136bad5cf58d_cc781905-5cde-3194_bf358-
The spine development of the child in the womb is completed in the first three months, along with the development of its organs. During this period, the growth of the vertebrae becomes asymmetrical as a result of the abnormal formation of the spine structure or staying together, and as a result, curvatures develop. The type of deformity seen depends on where and in which direction the abnormal vertebra is located in the spinal column.
Defects that occur in the womb of the vertebrae can be seen in the form of formation defects and separation defects. There are also more complex cases where both defects occur together. An important point to be noted is that although these abnormal spines are present at birth, there may not be much curvature at first. Curvature occurs mostly with growth. But despite growth, many of the spines affected in this way may have little or no curvature at all. Even in vertebrae containing more than one abnormal vertebra, if these abnormalities are distributed in such a way that they balance each other, the result may be decreased trunk growth rather than increased curvature. The curvature may increase very slowly until the rapid growth stage of puberty.
In cases where one side of the vertebrae cannot separate and remains attached, the attached side cannot grow; the free side continues to grow and becomes skolyoz . In cases where both sides of the vertebrae are attached, there is little or no growth in this region. As a result, scoliosis does not develop, but this region may be short. If the vertebrae are attached from the front, because growth will continue from the back, then humped (kyphosis) occurs. If the vertebrae are attached from the back, because growth will continue from the back, it occurs cukurluk (lordoz) .
Half or insufficiently formed vertebrae cause one side of the spine to grow more than the other, creating a curvature.
Congenital scoliosis is not generally considered to be hereditary. But congenital scoliosis may accompany an inherited disease with other conditions that may be inherited. For this reason, there is no increase in the probability of a child with only congenital scoliosis finding and no other genetic disorder having another sibling with similar findings in the family. The exact cause of congenital scoliosis cannot be explained.
Due to a number of events occurring during the developmental stage of the embryo and fetus, some conditions may be seen more frequently with congenital spinal deformities. Some of these are those:
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Kidney, bladder system abnormalities - 30%
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Spinal cord abnormalities - 15%
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Congenital heart problems - 12%
In addition, congenital spinal deformities may be associated with various syndromes.
Symptoms
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Sideways curvature, abnormal hump, or abnormal inward curvature.
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Skin abnormalities on the back: increased hair growth, dimples, color changes.
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Abnormally long arms or legs.
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Uneven shoulders, waist or hips.
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Disproportionate shortness of the trunk relative to the legs.
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Balance disorders.
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Back protrusions noticed when the person leans forward.
Diagnosis
The diagnosis of congenital scoliosis is made primarily by examination. Special X-rays, Magnetic Resonance (MRI) imaging, ultrasound, and other tests may be required. The results of these investigations provide information about the related problems and can guide how the deformity will behave in the future.
Treatment
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monitoring
At this stage of scoliosis, how the deformity behaves is monitored. This is done with regular examinations and x-rays at certain time intervals. Unless there is an increase in curvature, it continues until the skeletal system reaches maturity without special treatment (it should also be done after surgical treatment).
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corset treatment
One of the biggest differences between congenital scoliosis and idiopathic scoliosis is that braces are not effective in congenital deformities. Sometimes the body creates a second curve to maintain balance above or below the curves caused by congenital abnormalities. These curvatures may increase after a certain time and sometimes reach more serious dimensions than congenital curvature. The brace can be used to control or delay the progression of secondary curvature in these patients.
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Surgical treatment
The most effective treatment in congenital scoliosis is known as slowing down or destroying the asymmetrical growth of the abnormal vertebra. This can be achieved with the most preferred spine fusion process (freezing the spine, eliminating motion). Surgery may need to be performed when the child is young to control an increasing deformity. Parents understandably fear that early fusion (as the fused portion is stopped growing) may inhibit stem growth. Although it is true to a certain extent, the trunk may not be recovered by correcting a very severe deformity after the growth is over, and delaying the surgical treatment of the patients just because of this concern may cause very serious problems for the patient in the future.
Early surgery can be performed at any age when necessary for a patient with congenital scoliosis, but it can usually be delayed until the patient is 1 year old. After this age, if surgical procedure is necessary for scoliosis, it is recommended to be done without waiting. Although early surgery is performed, additional procedures may be required for scoliosis if the initial surgery does not fully control the curvature.
Actively growing children may require both anterior and posterior fusion to control the scoliosis curvature. These techniques can be applied in both scoliosis and kyphosis. Spinal fusion to provide either autograft (the person's own) or allograft (a combination of many of these bone, bone, or many of these sources), bone may need to be used. If other related organ problems are detected, their treatment should also be planned. The treatment of these anomalies, especially those in the spinal cord, should be done together with spinal curvatures. While some spinal cord abnormalities do not require treatment, others are treated with surgery before or simultaneously with curvature treatment.
Rib abnormalities and inadequate chest development are observed in some patients with congenital scoliosis. In these children, rib cage abnormality can be corrected and the curvature can be controlled without fusion with rods placed in the rib cage. Periodic extensions every 6 months may be required in these patients.
In spinal curvatures, curvatures that occurred at an earlier age may be transferred to adulthood, as well as in people who have not had a curvature before, spinal curvatures may occur in adulthood for various reasons.
The curvature of the spine has a concave side and a convex side. On the concave side, compressive forces cause overloads on the facet joints that provide intervertebral movements; this pressure can cause the nerves to be compressed within the canal. In addition, excess bone formations in the joints or thickening of the soft tissues due to wear on the spinal structure can also increase nerve compression.
Adult degenerative scoliosis
Adult degenerative scoliosis is a type of scoliosis that occurs as a result of aging and wear and tear of the spinal structure. It usually occurs in people over the age of 50. It can also be one of the causes of adult degenerative scoliosis, which occurs at this age, as well as an increase in curvature. Osteoporosis is a disease that occurs with the decrease of calcium in the bones, also known as osteoporosis among the people.
Degenerative scoliosis that occurs with wear can be seen in any of the neck, back and waist regions of the spine; However, the most common area is the waist region.
The stability and balance of the spine may be impaired in people with advanced adult degenerative scoliosis. This disorder may cause the trunk to tilt to the side with the spine in the foreground and background, and the trunk to lean forward with the decrease in the anatomical angle of the lumbar region. These imbalances can cause an increase in the severity of the curvature, as well as affect the patient's mobility and cause pain.
In adult patients with degenerative scoliosis, back pain, low back pain and pain along the distribution area of the nerve (radiculopathy) due to nerve compression and loss of strength in the muscles fed by the nerve can be observed. In some cases, one of the vertebrae may slide forward, backward or sideways as a result of excessive deformation of the spine and being under load.
In these deformities that may occur in the spinal structure in addition to adult degenerative scoliosis, the forward shift of the spinal bone is called spondylolysis, the backward slippage is called retrolysis, and the lateral shift is called lateral lystesis. Bone shifts in the spinal structure can cause pain, as well as leg pain and muscle weakness due to nerve or spinal cord compression.
Symptoms
In adult scoliosis, the patient usually notices the deformity and balance disorders in the trunk himself. At the same time, they may notice the curvature with signs such as shortening in height, lack of clothes or not standing well. However low back pain and loss of strength usually appear as two important complaints that take the patient to the doctor. Difficulty in standing up after sitting for a long time, difficulty in walking in the first steps, spasm in the back and waist muscles, a gradual decrease in walking distance over the years, and a feeling of fatigue in the legs can be seen as the main complaints.
Patients with severe nerve compression may also experience loss of strength and numbness in the legs. Difficulty in breathing and fatigue can also be seen in patients with scoliosis of the back region.
Tmoment
The patient's complaints and the degree of curvature of the scoliosis are among the important factors affecting the treatment decision. The person should give detailed information about his/her complaints to the doctor. After this process, the doctor may evaluate the patient's complaints and request the following tests:
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Direct radiographs: Anterior, posterior and lateral waist radiographs and standing scoliosis radiographs.
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Magnetic resonance imaging (MRI): If there is pain in the legs, loss of strength, changes in urinary and defecation functions, magnetic resonance imaging may be necessary.
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Computed tomography (CT) - MyeloCT: The doctor may order a CT, especially if more detailed imaging of the bone is necessary.
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Electrophysiological tests: These tests may be requested in order to understand the level of nerve compression, especially in patients with leg pain, and to reveal whether nerve damage is due to the spine or diabetes in patients with diabetes.
Treatment
The method to be chosen in the treatment of adult scoliosis is decided according to the degree of pain and curvature, and whether the curvature is progressive or not. Generally, the first treatment methods to be applied to the patient are non-surgical treatment methods. Exercises to increase physical condition, stabilization, strengthening and stretching exercises, accompanied by a physiotherapist, can relieve muscle spasm and reduce pain. However, it has not been fully demonstrated that these exercises have a role in preventing the progression of a progressive scoliosis.
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Physical therapy and exercise
Generally, the first treatment methods to be applied to the patient are non-surgical treatment methods. Exercises to increase physical condition, stabilization, strengthening and stretching exercises, accompanied by a physiotherapist, can relieve muscle spasm and reduce pain. However, it has not been fully demonstrated that these exercises have a role in preventing the progression of a progressive scoliosis.
Along with physical therapy and exercise pain relievers may also be given for patients with pain. In addition, irritation especially in the facet joints or as a result of nerve compression; Non-steroidal anti-inflammatory drugs can also be added to the treatment to relieve irritation (inflammation). If the source of pain is for radicular pain caused by worn facet joints or nerve compression, spinal injections may be a good alternative treatment method for these patients.
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Corset Treatment
Brace therapy should be considered for a short period of time as an adjunct to exercise and physical therapy. In patients with adult scoliosis, long-term brace treatment may cause more harm than good.
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Surgical treatment
In adult scoliosis, pain, loss of function and balance are more prominent than the degree of curvature and the deformity problems caused by it. However, although it is painless, surgery may be necessary to stop the further progression of scoliosis that has clearly progressed.
Scoliosis surgery can be an important alternative method for patients who do not respond to treatment despite all non-surgical methods, whose pain increases during this period (between 6 weeks and 6 months), and who suffer from disability. In addition to curvature, if patients have loss of urine, defecation control or loss of muscle strength due to severe narrow canal or nerve compression, scoliosis surgery can be selected for treatment.
Adult scoliosis surgery is more challenging than pediatric and young age scoliosis surgeries. The duration of surgical intervention and the number of scoliosis operations performed on the person may also be higher. On the other hand, heart, lung, diabetes and osteoporosis diseases are among the important information that should be reported to the doctor for scoliosis surgery.
The aim of scoliosis surgery is to correct the curvature to balance, fusing the vertebrae (fusion) and eliminating nerve compressions (Decompression).
After adult scoliosis surgery, the patient is kept in the hospital for 5-10 days for the recovery and rehabilitation process. post-operative patient can usually stay in the intensive care unit overnight. On the first day after scoliosis surgery, the patient is seated by the bed and leg exercises can be performed. On the same day or the next day, the patient is moved (the patient needs to stand up and walk a few steps).
After the patient is discharged, an exercise program is given to him. The patient starts to apply this program. The results of the treatment are evaluated by the doctor's regular check-ups. In this whole process, it is aimed to return the person to his normal life as soon as possible.