scoliosis is an evolutive
disease, in which are one or more lateral curves of the vertebral
column, that we can see in a frontal plane; also , there is present the
rotation of the vertebrae. The curves are compensate at superior and
inferior level, but don’t exist reductibility in suspension
factors of the
There are many ethiologycal factors
propose for the apparition of torsion to vertebral column, but it is
very hard to say if the anomaly observed is the cause or the
consequence of the deformity of the vertebral column.
In 1968, Wynne-Davies(1) proposed a
multifactorial transmission, after studying 114 cases, in which 28%
there were a familial scoliosis.
In 1972, Cowell(2) studied 110 cases
and concluded that in 68% and in 36% of cases the genitors and the
brothers or sisters had scoliosis.
The genetic factors are evident for
the idiopathic scoliosis. The disease has not genetically transmission,
but the ethiologycal factors allow in some circumstances the apparition
of this morphological aspects.
We don’t know wich is the real way
of transmission, but we know that the genetic factors are
multifactorials and their expression may be influence by environmental
The importance of
growth in the
development of idiopathic scoliosis is known since the XIX th century.
There have been
The growth is
necessary for the
apparition of scoliosis
The progression of
the deformity is
important at the age of rapid growth (pubertary age)
scoliosis(with low angle)
are relatively stable at the end of the bone maturity.
Many authors have
existence of scoliosis in diseases that affect the connective
tissue(Marfan disease, Ehler-Dunlos disease, imperfecta osteogenesis).
These aspects suggests that the collagen and the proteoglicans are
important in the apparition of scoliosis. It is difficult to say if
these alterations of the two main components of the connective tissue
are preexistent or are secondary to the deformity of the vertebral
and balance factors
There are many
experimental factors that are important for the nervous regulation and
the postural balance in the development of idiopathic scoliosis. The
purpose of the balance system is to resist in front of gravitational
forces and to control the movement and the eyes position. The
afferences are generate in the proprioceptors (tendons, ligaments,
joints surfaces, muscles), in the ocular and vestibular system. The
impulses are integrate in the cerebral trunk and cerebellum and the
efferences will be transmitted to the skeleton through the
vestibulo-spinal and the reticulo-spinal ways.
Yamada had observed
in 150 cases of
idiopathic scoliosis that in 79% of cases there were anomalies of the
balance function, proprioception and oculomotor reflexes. In the
witness group were only 5% of cases with such anomalies it is very
interesting that these anomalies disappear at maturity(20 years). So we
can suppose that there is a delay in the maturation of the nervous
system, not a disease of the nervous system.
The authors also
observed that the
central otholitic function is altered in idiopathic scoliosis. The
primary or the secondary character of this alteration cannot be
In conclusion, the
alteration of the
vestibular function is evident in idiopathic scoliosis, but it is very
hard to define the neurological level of the disfunction. But the most
important thing is that this neurological disfunction is transitory.
There have been
made many studies to
asses the muscular ethiology of the idiopathic scoliosis. Many authors
have observed that the ATP-azical activity in the paravertebral
muscular fibers is low and the intracellular calcium level is high. For
that reason, has been proposed a general anomaly of functioning of the
From that point of
view, we can
consider that the idiopathic scoliosis is a consequence of a
genetically transmitted miopathy.
Melatonine is a
hormone of the
pineal gland. In 1959, Marie-Jeanne Thillard(3) discovered that the
pineal ablation produces scoliosis. In 1993, Machida(4) and
Dubousset(5) published an experimental study in which reimplantation of
the pineal gland has a protective effect in the development of a
All the studies
suggest that it is
necessary a normal concentration of melatonine for the harmonious
development of the nervous system and balance system, with consequences
on the symerty of the orthostatical position.
Melatonine is a
acts on the central nervous system (proprioceptive pathways in medular
thalamus, cerebral trunk, medular spine). Another role of melatonine is
hormonal, in growth. From this point of view, we can try the treatment
with melatonine in the case of evolutive scoliosis at the age of
biomechanic of idiopathic
In the scoliotic
curve, all the
vertebral are in extension if the vertebral rotation is greater than
90°, the vertebral column become pseudo-kyphosis, but in that
, too, the vertebres are in extension.
The thoracic and
deformations(the gibosity at the level of the convexity of the curve),
that are so important clinically, are the consequences of the vertebral
progression of the scoliosis
alterations(vertebral, ligamentar, muscular) are moderate until the
scoliosis has a lower angle(20°-30°) and the curves may
with a correct treatment. The angle of 30° represents a
level because an elevated value means the presence of a deformity and
progression of the scoliosis
progressive until the age of bone maturation and then it is stabilize.
But Ponsetti observed that if the curve is greater than
in the end of the growth, the aggravation of the scoliosis is
Natural and Evolutional
History of idiopathic scoliosis
The concept of
aggravation for the
pubertary growing period it was known before Ponsetti (6) and Friedman,
who described in 1950 two possibilities of scoliosis aggravation:
If the scoliosis
arise before the
age of 10, this remains often constant and slow evolutional for a
period of few years, further abruptly aggravates.
If scoliosis arise
after the age of
10, it will aggravate on a regular basis, so that a prognosis can be adopted
after 2-3 succeeding
If the aggravation
is slow after
more radiological examinations, prognosis is good.
prognosis appears if
aggravation is fast.
For the curves more
than 10 degrees,
RISSER test is a good part of prognosis: if RISSER is 0 the aggravation
risk is 68 %, and if RISSER is 3-4 the aggravation risk is lower 18%.
In 1984, Lonstein
patients with idiopathic scoliosis, whom initial curve range between 5
and 29 degrees, and he is looking to find the identifiable risk
For him, the
progress risk of
scoliosis depends on the topography curve, the age it has been
discovered, the initial grade of amplitude, RISSER phase, and the first
time of menses. The aggravation risk is lower if the RISSER test arises
an aging boned, (aging osseous) more advanced. So, for a RISSER phase
that is 0, the aggravation risk of one curve inferior to the 20 degrees
angle is 22 %, and for a curve superior to the 20 degrees angle is
three times higher. It is a direct correlation between COBB angle,
RISSER test, and the chronological age, turned into the following
equation by Lonstein:
The risk quotient =
(COBB angle – 3)
x RISSER test/ chronological age
Vidal described three
evolutional possibilities, according to the scoliosis type:
immediately, sometimes brutally, and they can be to 90 degrees:
curves, the aggravation
is different. If the angle appears before 6 year old, this remains
constant and inferior to the 30 degrees angle. Aggravation appears
between 6 years old and the age of pubertary, and the angle gain could
range between 25-30 degrees on year.
scoliosis presents a
large evolutional type, the angle at the end of development ranging
between 10 and 90 degrees.
of evolutional risk
of debut age
In 1962 Cotrell
classification on 5 groups:
before 3 years old exceed frequently 100 degrees ageing boned, (osseous
break down in 3
age groups, between 3 and pubertary – the percent cases, that
increasing to an angle more than
50 degrees, decreases in the same time with the debut age, ranging
between 83% and 55%.
pubertary to the ageing boned, (osseous ageing) – rarely are
50 degrees angle.
boned, (osseous ageing)
and the residual growing
test is easily
recognize and differentially Risser 0 and Risser 1, but it’s
difficult to say that RISSER is 5, without having a global picture of
RISSER 1 and RISSER
2 appear in the
majority of cases between 13-14 years old to the girls, and 14-15 years
old to the boys, referring to the osseous age. For RISSER 2 the
scoliosis risk decreases, and practically it will become null for a
curve lesser than 20 degrees. If RISSER is 3 or 4, the child is on the
descendent part of his pubertary growing, and the growing peak is on
the thoracic chest.
growing of thoracic chest may produce the curve decrease.
osseous age of vertebres
can be assesse by Ring test, which correspond to the vertebeas
ossification, and take the aspect of a “leaf” seen
from front and
lateral, then a more regular track, going to complete seam in anterior
part, which correspond to the closure of aging osseous.
Weinstein in 1985
parallelism between the risk progression of scoliosis and the initial
angle. This confirms Stagnara’s researches, which considers
degrees angle as being critical, because if this is bigger then all
scoliosis are evolutional, if it’s less than 30 degrees than
two cases evoluate before pubertary period.
topography of the curve
In 1950, Ponsetti
and Friedman had
shown the evolutional differences connected to the type of the curve,
break them down in thoracic curves, double-major, thoracic –
the most deformed curves at the adult age, and also the result of the
precociously forms, with a large evolution. Stagnara described them as
being the most powerful forms, because they go beyond 90 degrees,
induct a thoracic deformation and a restrictive respiratory syndrome,
which aggravates the vital prognostic for the adult age.
– lumbar scoliosis have
a better prognostic, but induct an important esthetically prejudice.
The double major
scoliosis are often
lumbar and dorsal, producing an esthetic prejudice relatively smaller
for the angles that are exceed 40 degrees This is not happening in the
thoracic double dorsal deformations and dorsal – lumbar,
a severe esthetic prejudice by shoulders’ unbalance.
statistical point of view are the less evolutional in development
period, the angle and the esthetic prejudice being moderate, but the
degradation risk for the adult age being important. At this level, the
spinal segment is more mobile because the relative inflexibility effect
attached to the thoraces , disappears, the scoliosis can grow in
three-dimensional sides. The right deformations are two times more
evolutional then the left ones and a satisfactory explanation can not
scoliosis evolution after
spinal pain frequency for people with scoliosis is 80%
to the general population. The pains frequency is more important in
lumbar scoliosis or dorsal – lumbar, because of the lateral
dislocations from the inferior extremity of the curve. In lumbar
scoliosis and dorsal – lumbar cases, the pains can also
appear at the
compensatory curves. In most cases these pains emerge at the end of the
work day. They are calm down by rest, and have a variable topography,
which generally is not correlated location and amplitude of deformation.
The most frequent
causes of these
pains are ligament distensions and the dyscopathy lesions
– respiratory deficit
in the dorsal
scoliosis. The major thoracic scoliosis straitens the back circulatory
system and can involve the occurrence of one chronic pulmonary heart
and right cardiac insufficiency.
scoliosis patients’ longevity
In 1968, Nachmson
did a research on
130 patients with scoliosis, who had the major thoracic curves more
than 90 degrees. In this group at the age of 50 the mortality was three
times more than normal, and the reduction of the vital capacity was 50
dosen’t go up the risk
of progressive scoliosis. This risk dosen’t correlate with
patient’s age at the first gestation or with the number of
prognostic determination at
the first clinical examination
The problem of
before the scoliosis is close to 30 degrees. The most powerful
aggravations appear in the cases of short thoracic curves, while the
long curves have less risks of further deformation.
The clinical exam
is the most
important, and the appearance of lumbar unbalance, or shoulders
unbalance are not that relevant prognosis signs.
The Cobb angle
dosen’t have by
itself predictive value, because it must be compare with the
three-dimensional deformation, and with residual growing.
The most important
is to evaluate
the residual growing, which can aggravate the risks factors.
The global clinical
necessary to eliminate the presence of a secondary scoliosis, and
morphological exam can show signs with an adverse character of the
curve global hypotrophy, amyotrophy, balance disorders, ligamentars
laxity, without forget to verify the intelectual capacity and the
adaptation to a possible treatment.
The clinical and
leads to a right prediction of 92% from cases. Is important to
understand that 8% from cases are errors and incertitude, and so we
must to try solving the mystery of ethiopatogeny scoliosis.
(1968). Familial (idiopathic) scoliosis Bone Joint Surg, 50,
JN, MacEwen GD.(1969). Familial patterns of idiopathic scoliosis. J
Bone Joint Surg [Am] 1969; 51: 1236.
Queneau, P.; and
Thillard, M. J.(1983). Experimental scoliosis induced by pineal and
diencephalic lesions in young chickens. Its relation with clinical
findings in idiopathic scoliosis. Orthop. Trans.,
Machida, M., Dubousset, J., Imamura,
Y., Iwaya, T., Yamada, T.,Kimura, J.(1995). Role of melatonin
deficiency in the development of scoliosis in pinealectomised chickens.
J. Bone and Joint Surg., 77-B(1):
Pedrini, V. A.,
Ponseti, I. V.,Dohrman,
S. C.(1973) Glycosaminoglycans of intervertebral disc in idiopathic
scoliosis. J. Lab. Clin. Med., 82: 938-950.
Taylor T.K., (1979).
Intervertebral disc colagen in adolescent idiopathic
scoliosis, J. Bone Joint Surg.
Burwell RG, Cole
AA, Cook TA.(1992). Pathogenesis of idiopathic scoliosis: The
Nottingham Concept. Acta Orthop Belg.; 58 (Suppl
G., Barhel F. (1983). La croissance des scoliotiques. Revue de
Chirurgie Orthopedique, 69, 201-206.
scoliosis. British Med. J., 1: 328-334, 1934
Sahlstrand, T., and
Petruson, B.(1979). A study of labyrinthine function in patients with
adolescent idiopathic scoliosis. I. An electro- nystagmographic
study. Acta Orthop. Scandinavica, 50: 759-769.