CHAPTER XVIII

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.

_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.

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).

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.

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_.

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.

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.

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_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.

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.