Radiologists very frequently see scoliosis cases. It is important to describe the biomechanical etiology of the so-called idiopathic scoliosis [Adolescent Idiopathic Scoliosis (AIS)], early and advanced changes in radiological examination of the spine.

Keywords: So-called idiopathic scoliosis, New classification, Radiological symptoms

SPINE – SCOLIOSIS [1-22]

The etiology of AIS was described in Lublin in years 1995-2007. Discovered causes inform about biomechanical influences in the development of the spine and inform about the stages of deformity.

In X-ray we observe four stages:

1.       Rotation changes in spine with its normal axis or beginnings of curves,

2.       Development of curves and stages of this deformity,

3.       Changes in the shape and the position of pelvis and sacral bone

4.       Development of degenerative changes in the inter-vertebral joints.

Classification and comments: Causal influences and properties of scoliosis in points

There are three groups and four types of spine deformity (Figures 1 and 2):

1.       “S” scoliosis in 1^st group, “C” and “S” scoliosis in 2^nd group, “I” scoliosis in 3^rd group.

2.       Till now in medical literature it has been mostly spoken about the “S” scoliosis in 1^st group.

3.       All types of scoliosis start to develop at 2-3 years of child’s life.

4.       The development of scoliosis in every group and type is connected with biomechanical influences - “walking” and “standing ‘at ease’ on the right leg”.

5.       In gait – there is an asymmetry of movements between the left-right side of various parts of child’s body, in pelvis and in the spine. In standing – there is an asymmetry of the time of standing ‘at ease’ – left versus right leg – standing on the right leg longer or only (!).

6.       At the beginning of the oncoming of spine deformity we observe clinically and radiologically a rotation deformity of the spine. Explanation: the limited movement of right hip, during gait, as compensatory movement is transmitted to the pelvis and spine and makes “the rotation – distortions in inter-vertebral joints” and as result “the stiffness”. 

7.       In older children we observe clinically and radiologically curve.

8.       In youth and adults we observe an asymmetry in the position of pelvis and sacrum bone and next degenerative changes. 

EXPLANATION OF ALL ASYMMETRIES

In all children with scoliosis there is an asymmetry of movement of hips. These asymmetries are a part of the clinical symptoms of the “Syndrome of Contractures and Deformities” according to Prof. Hans Mau (originally in German it is “Siebener syndrome” [1-4,15-22]. All these asymmetries are a primary cause in the etiology of scoliosis. In all children with scoliosis there is a limited movement of the right hip – especially adduction in strait positing of the joint. In some patients with scoliosis there is also limited internal rotation and extension of the right hip. Because of this the right hip is more stable and all children with scoliosis have the habit to stand ‘at ease’ only on the right leg. Next, this “limited movement” has influence as “compensatory movement” to pelvis and spine, what was mentioned above.

Materials

In the years 1985-2018 in observations and in treatment there were - 2500 patients mostly aged 5 to 18. Another group of patients was older (60-80 years), coming with the problem of spine pain. Older people mostly had degenerative spine deformities, and in the new classification there were cases from the 2^nd group of scoliosis. According to our observations 80 % of older patients have “painful changes” in the lumbar spine, 20% in lumbar and thoracic spine.

Classification important for radiology specialists. Explanation of the development of scoliosis [5-14] Clinically, in all scoliosis patients the movement of hips is asymmetrical. In the first place, the adduction in strait position of joints is asymmetrical. The right hip adduction, internal rotation and in some cases also extension are limited. There are three groups and four types of these hip asymmetries and the three groups and four types of scoliosis are connected with these asymmetries:

1.       Scoliosis “S” 1^st etiopathological group (epg) (Figure 3) - double curve. Right hip adduction is 0 or (-) 5 (-) 10 degrees. Left hip adduction is 30 to 50 degrees. Stiff spine (3D). Rip hump on the right side of thorax. Connection with gait and standing.

2.       “At ease” on the right leg. There is a large asymmetry of movements of hips. The absent/very limited movement of the right hip is transmitted to the pelvis and the spine. Next, a permanent rotation movement in infer-vertebral joints in a form of distortion appears, in every step – the result is stiffness of the spine. Because of the asymmetrical standing, longer on the right leg – the loading on the right leg lead to the development of curves.

·         Scoliosis “C” 2^nd/A epg (Figure 4) – one curve – lumbar left convex. Right hip adduction is 15 to 30 degrees. Left hip adduction is 30 to 50 degrees. Spine flexible (1D or 2D); Connection only with standing “at ease” on the right leg.

·         Scoliosis “S” 2^nd/B epg (Figure 5) – two curves (2D or 3D); Right hip adduction is 15 to 30 degrees. Left hip adduction is 30 to 50 degrees. Connection with standing ‘at ease’ on right leg and additionally connected with the laxity of joints and/or harmful previous exercises. In both types of scoliosis the spine is flexible.

In the “asymmetrical standing” the loading on the right leg is permanent, lasts longer, and because of this it leads to the development of curves. In scoliosis 2^nd epg group comes to “C” deformity in lumbar spine. The clinical symptom in all cases is the lumbar left convex curve.

In 2^nd/B epg additionally it comes to the development of thoracic right convex curve.

3.       Scoliosis “I” 3^rd epg (Figure 6). Deformity is in a form of stiff spine (2D or 3D). No curves or small ones. The cause is gait only. Right hip adduction is 0 or (-) 5 (-) 10 degrees. Left hip adduction is 0 to 15 or to 20 degrees. Such “spine deformity” till 2004 has never been included to the “scoliosis deformity”. 

In the “asymmetrical standing” the loading on the right leg is permanent, lasts longer, and because of this it leads to the development of curves. In scoliosis 2^nd epg group comes to “C” deformity in lumbar spine. The clinical symptom in all cases is the lumbar left convex curve.

In 2^nd/B epg additionally it comes to the development of thoracic right convex curve.

4.       Scoliosis “I” 3^rd epg (Figure 6). Deformity is in a form of stiff spine (2D or 3D). No curves or small ones. The cause is gait only. Right hip adduction is 0 or (-) 5 (-) 10 degrees. Left hip adduction is 0 to 15 or to 20 degrees. Such “spine deformity” till 2004 has never been included to the “scoliosis deformity”.

RADIOLOGICAL CHANGES IN VARIOUS TYPES OF SCOLIOSIS AND IN VARIOUS AGES OF PATIENTS

Scoliosis “S” in 1^st type (Figure 3). In X-ray examination of young people, the rotation deformity of the spine comes first. The processi spinosi are twisted to the side – in lumbar spine to the right side, in thoracic part – to the left side, and this occurs deep under the skin. Clinically the spine is stiff. 

Its position, as described above, is deep under the skin especially in segment Th 6 – Th 12.

In older persons – in X-ray examination in the lumbar part there are degenerative changes with osteophytes.

Scoliosis “C” in 2^nd/A and “S” in 2^nd/B (Figures 4 and 5) type of deformity in children, there is only a curve in lumbar part and in thoracic part (in “S” scoliosis) to be observed.

In adults, degenerative changes appear. In this group of people, the progression of deformity is connected only with the permanent standing ‘at ease’ on the right leg (!).

Scoliosis “I” in 3^rd type of spine deformity (Figure 6). Clinical symptoms in this type of pathology are only stiffness of spine. In X-ray the curves are minimal or absent. Only rotation deformity is present as disappearing of the processi spinosi. In lumbar part they are deep on the right side, in thoracic part there are deep on the left side.

In all types of scoliosis – The X ray examinations should be taken with the pelvis. Technical information: to take X-ray pictures, the patient should be standing symmetrically, on both legs. Remember – standing ‘at ease’ on the right leg shows bigger curves, standing ‘at ease’ on the left leg shows smaller curves (Figures 7a-7c). In older patients (the time is important for the development of changes) the radiologist should observe the changes in the position of pelvis – very often it is an oblique position. The “inner light of pelvis” is asymmetrical. We observe an oblique position of the sacral bone very often. With the time develop the degenerative changes in the spine (Figure 8). It is connected with the “permanent standing over years on the right leg”.

THERAPY AND PROPHYLAXIS OF SCOLIOSIS

We present the rules of treatment in points:

1.       Every doctor should inform patients about the dangerous of the “standing “at ease” on the right leg”. Permanent standing on the right leg over years is the “first cause of the pain of the spine” for many patients in many countries.  

2.       In problem of back pain – the patients should be informed about the proper sleeping position. The best and relaxing one is the “embryo position”.

3.       Patients with “spine problems” should be directed to rehabilitation centers and not undergoing “surgery”. In the therapy, a proper exercises are: kinesiotherapy exercises lying down on the side, or on back - never lying “on stomach” and various kinds of active movement. Important is the “extension/pulling” treatment for lumbar spine – the patient is lying on their back and hanging “on the legs with the hips and knees flexed to 90 degrees. Other proper therapies are: massage, diadynamic, laser and other physiotherapy methods. 

4.       “Stretching exercises” are especially profitable for hips, knees and spine. For example exercises typical for yoga or other similar. Here we inform – muscle strengthening exercises are totally wrong, they are the cause of “iatrogenic deformity and illness”.  

DISCUSSION

The etiology of the so-called idiopathic scoliosis was described in years 1995-2007. In children with the so-called idiopathic scoliosis the problem is cosmetic and functional. In older people – scoliosis cause pain, especially in the lumbar part of the spine. First of all, “pain syndromes” should by treat by physiotherapy and not by surgery (!). As a reason for diagnosis, many doctors mention the “prolapsed nucleus pulpous” and suggest a surgery. Such a diagnosis is not correct and the proposed therapy is not proper or even totally wrong.

CONCLUSION

1.       The etiology of the so-called idiopathic scoliosis is strictly biomechanical. There are three groups and four types of the spine deformity: “S” scoliosis in 1^st type, “C” and “S” scoliosis in 2^nd A and B type, “I” scoliosis in 3^rd type of scoliosis. 

2.       The development of scoliosis and the type of spine deformity is connected with pathological “model of hip movements” and function – “standing ‘at ease’ on the right leg” and “gait”.

3.       The restricted range of movement in the right hip is connected with the “Syndrome of Contractures and Deformities” according to Prof. Hans Mau.

4.       The causes of back pain syndromes in adult patients are:

·         Hyperlordosis in the lumbar spine,

·         Degenerative left convex lumbar scoliosis - “C” and “S” scoliosis in II/A/B epg,

·         Stiffness of spine - “I” scoliosis in III epg,

·         Spondylolisthesis,

·         Other anomalies of anatomy of spine.

5.       In X-ray we observe – rotation deformity, curves, changes in the anatomy of lumbar and thoracic parts of spine. Advanced changes are connected with age. Degenerated changes occur in older patients mostly over the age of 40.

6.       The proper therapy of “scoliosis” in children is only – a/ standing ‘at ease’ on the left leg and b/ “stretching exercises” and never “strengthening exercises”. Additionally – c/ physiotherapy and especially massage.

7.       Surgery is reserved only for cases with “long lasting pain syndromes” and paresis of the foot cases. 

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