Scoliosis This section was compiled by Frank M. Painter, D.C.
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FROM: Physical Diagnosis: Procedures and Methodology in Chiropractic Practice
Chapter 17 ~ Physical Examination of the Lungs and Thorax
By Richard C. Schafer, D.C., FICC
The complex subject of scoliosis is briefly described in this chapter because its gross manifestations occur in the thoracic area. It should be readily recognized, however, that spinal curvatures sometimes find their primary cause in the lower extremities, pelvis, lumbar region, or cervical spine.
THE THORACIC CAGE
The thoracic cage serves as a unique biomechanically coupled system, composed of the sternal complex, 12 pairs of ribs, costal cartilages, and thoracic vertebrae. As a whole and individually, these structures are quite strong and elastic prior to the degenerative processes and osteoporosis of old age. Morehouse/Cooper state that the thoracic cage of an infant can withstand compression loads up to 200 lbs without injury; young men can withstand up to 2,800 lbs.
History
A complaint of thoracic pain is often the result of referred pain. It is Cyriax's experience that C3 and C4 lesions usually refer pain to the base of the neck, C5 and C6 lesions commonly refer pain to the midscapular or interscapular area, and C7 lesions refer pain centrally to the midthoracic spine and/or unilaterally at the inferior angle of the scapula.
Diaphragmatic pain is typically perceived at the shoulder (C4 dermatome), while pain originating from the pleura that is not in contact with the diaphragm is perceived within the chest. In either case, the pain is usually exacerbated during deep inhalation and sometimes during trunk bending tests.
Topography and Applied Anatomy
The most commonly utilized vertical lines of reference anteriorly are(1) the bilateral midclavicular lines (which extend from the middle of the clavicles inferiorly to pass slightly medial to the nipples and end at the costal margins) and
(2) the central midsternal line. The angle formed by drawing oblique lines from a dot placed at the inferior termination of the midclavicular lines and the center of the xiphoid process is often of clinical significance.The most commonly utilized vertical lines of reference posteriorly are
(1) the bilateral scapular lines (which extend from the tips of the superior angles of the scapulae to pass inferiorly through the inferior angles of the scapulae and terminate at the crests of the ilia) and
(2) the midspinal line.
The Sternum
The sternum serves as a protective plate for the heart and aorta against anterior forces. Anatomically, the sternum is divided into three main osseous parts: the manubrium, the body of the sternum, and the xiphoid process (Fig. 17.1). (Please refer to Sternum anatomy)The Manubrium. The thick superior part of the sternum articulates laterally with the medial clavicles and the 1st and 2nd ribs. The jugular notch at the superior aspect of the manubrium is on a level with T2. The inferior aspect of the manubrium is on a level with T4 and joins the superior aspect of the body of the sternum in a synchondrosis, which allows hinge-like movements during respiration until ossification occurs in middle age.
The Body of the Sternum. The middle part of the body of the sternum is composed of four synchondrotic segments that become fused in the young adult. Its lateral aspects offer a series of costal notches to accept the anterior aspects of the costal cartilages. Fixations are sometimes found at these joints.
The Xiphoid Process. This coccyx-like process extends downward from the inferior aspect of the 4th segment of the sternal body and divides the superior aspect of the rectus abdominis. The joint between the body of the sternum and the xiphoid process, on a level with T8, is a synchondrosis that becomes a synostosis during middle age.
The Ribs
With the exception of an anomaly, each of the 12 thoracic vertebrae normally has a corresponding pair of ribs. A typical rib is angled inferiorly from its vertebral attachment as it curves outward and serves as a curved lever. The lower the rib, the more acute the angle. At its anterior aspect, each rib curves medially and upward. Except for the short 1st rib, this means that the lateral aspect of a rib is lower than either its posterior or anterior attachment. The anterior attachment is lower than its posterior attachment.
All rib angles increase with inspiration and decrease with expiration, and all rib lengths increase with inspiration and decrease with expiration. This is called the "caliper," "ice tongs," or "pump-handle" A–P effect. It occurs essentially at the costovertebral joints and is fairly restricted to the T2—T6 area.
Also during respiration, the lateral aspect of a rib raises and lowers with inhalation and exhalation. This lateral "bucket-handle" effect is due to the relatively fixed points of articulation anteriorly and posteriorly and the lateral inferior-superior motion. The lateral aspects of the ribs are pulled away from the midline and the transverse diameter of the thoracic cage is increased. This movement chiefly elevates and everts the lower borders of ribs T2-10. The effect is most noticeable in the upper ribs.The T1—T7 Area. These "true" ribs articulate with the sternum anteriorly. Their length progressively increases inferiorly. Due to strong attachments at the sternum and at the costovertebral and costotransverse joints, A—P distortion should be inhibited in this area. Yet, Grieve reports that it is not uncommon to find a flat midscapular area that is normal in all other respects. This could indicate that acquired biomechanical forces have overcome inherent structional forces.
The T8—T10 Area. The ribs of this area, called "false" ribs, are joined anteriorly below the sternum by cartilage with no direct osseous support. Their length progressively decreases inferiorly.
The T11—T12 Area. These ribs, called "false floating" ribs, are relatively free anteriorly, lacking both osseous and cartilaginous support. They end within muscle tissue. They do not actually "float" because they articulate posteriorly with their numbered vertebrae. Their length progressively decreases inferiorly. The 12th rib is attached to the tips of the L1 and L2 transverse processes by the lumbocostal ligament, which runs just anterior to the quadratus lumborum.Observation and Palpation
The thorax should be examined in a warm, well-lighted room. A thorough knowledge of topographic anatomy is essential (Fig. 17.2). The male patient should be stripped to the waist, the female patient draped. The majority of the examination is usually conducted with the patient seated with the spine erect unless the patient is bedridden or a recumbent position relieves pain.
Observation and Inspection
In screening the chest, look for the following points: (1) size, (2) general shape and nutrition, (3) local deformities or tumors, (4) respiratory movements of the chest walls, (5) respiratory movements of the diaphragm, (6) abnormal pulsations, (7) color and condition of the skin, and (8) the presence or absence of glandular enlargement.
Check symmetrical bony development, inequality in intercostal spaces retracted by a possibly unilateral fibrosed lung, and the normality of the dorsal kyphosis and the angles of the sternum. Appreciate every visible and palpable variation from the norm. When examining the front of the chest, it is often best to have the patient stand with the side to a window so that the light strikes obliquely across the chest, accenting depressions and making every pulsation a moving shadow.
Size and Shape
Small chests are seen in patients who have been bedridden for an extended period and those who have suffered in infancy from rickets, adenoid growths, or a combination of the two. Abnormally large chests are seen chiefly in emphysema. Of course, chests of healthy people vary a great deal in size at any given age.
There are marked differences in shape between a child's and an adult's chest in health. A child's trunk, as compared with that of an adult, is far more cylindrical; that is, the A—P diameter is nearly as great as the lateral. The adult's chest is distinctly flattened from front to back, although individual variations in this respect are considerable. In childhood, common pathologic conditions are adenoids and pneumonia (several decades ago it was rickets); in middle and later life, it is emphysema, pleuritic disease, cancer, tuberculosis, and brittle ribs. Signs of Pott's disease of the spine should always be sought during inspection of the chest. They are sometimes better felt than seen.
With the normal thorax, the shoulders should be level. The clavicles should not be unduly prominent, but there is ordinarily a moderate depression of both the supraclavicular and infraclavicular areas. A right-handed patient may show slightly greater muscular development on the right side of the anterior thoracic wall than on the left because of muscular development of the dominant side. The normal slope of ribs should be about 90° anteriorly, which increases with inspiration and in emphysema. The normal angle with the spine is about 45°, which also increases in emphysema but little during inspiration.
Types of Clinical ChestsThe Paralytic Thorax. The normal A—P flattening of the chest is exaggerated in a "paralytic thorax" to a degree that such people are called "flat chested." The clavicles are prominent owing to falling in of the tissues above and below them. The shoulders are stooping, the scapulae are prominent, and the neck usually appears long. The angle where the ribs meet at the ensiform cartilage (costal angle) is sharp. This type of chest has often been said to be character- istic of phthisis, but it may be found in persons with perfectly healthy lungs. On the other hand, tuberculosis frequently exists in people with normally shaped chests or with abnormally deep chests.
The Barrel Chest. The most striking characteristic of a "barrel chest" is its greatly increased A—P diameter so that it approaches the form of an infant's chest. In many aspects, it is an exaggerated form of the normal mesomorphic chest: the costal angle is obtuse, the shoulders are high, and the neck is short. Emphysema should be the first suspicion.
The Rachitic Chest. The rachitic sternum generally projects (pigeon breast), but in some cases, especially when rickets is combined with adenoid hypertrophy, there may be a depression at the root of the sternum resulting in a "funnel breast." The sides of the chest are compressed laterally and slope inward to meet the sternum like the sides of a ship slope downward to meet the keel (pectus carinatum). From the origin of the ensiform cartilage, a depression or groove is seen running downward and outward to the axillae, roughly correspond- ing to the attachment of the diaphragm. This is called Harrison's groove. The lower margin of the ribs in front often flares out, owing to enlargement of the liver and spleen below and the pull of the diaphragm from above. Along the line of the chondrocostal articulation, there can be felt, and sometimes seen, a line of eminences or swellings, which is named the "rachitic rosary."
The nutritional status of the thoracic walls should be appraised. Emaciation is readily appreciated by inspection. The ribs are unusually prominent, the sca- pulae stand out, and the clavicles project. All this may be seen independently of any change in the shape of the chest as was described above with the paraly- tic chest. Tuberculosis of the apices of the lungs may produce a marked falling in of the tissues above and below the clavicle that is independent of any emaci- ation of the chest itself. Note musculoskeletal development and the general appearance of the skin (eg, smooth, supple, dry, oily), hair, and breasts.
Palpation Procedure
Palpation helps to confirm signs noted on inspection, as does percussion and auscultation. Check contours, consistencies, lumps and swellings. Palpate the dynamics involved in the respiratory movements with your hands splayed widely. Check superiorly and inferiorly on both the front and back. Expansion, checked during both quiet and deep inspiration, may be limited by acute pleurisy, fibrous thickening of the pleura, fractured ribs, or other trauma to the chest wall.
Note tactile fremitus of the spoken voice. Crepitation may be palpated when the subcutaneous tissues contain fine beads of air (subcutaneous emphysema), caused by air escape from the lung (eg, trauma).
Deformity
Paralytic, barrel, and rachitic chests are symmetrical and affect the whole thorax. Here we shall consider chiefly those abnormalities that affect particular portions of the chest and not the thorax as a whole.Spinal Curvatures. Slight degrees of deformity are best seen by marking with a skin pencil the position of the spinous processes. The more marked cases of lateral curvature, which are accompanied by a degree of rotation, give rise to considerable displacement of the thoracic organs and render unreliable the usual bony landmarks, with reference to which we judge the position of the intrathoracic organs. In gross deformities, the apex of the heart may be pushed up into a level with the 4th intercostal space or out into the axilla, or portions of the lungs may be compressed and made atelectic. The bulging on the convex side of the curve may simulate an aneurysmal tumor.
Flattening of One Side of the Chest. In chronic cirrhosis of the lung, phthisis, or long-standing pleurisy (serous, fibrous, or purulent), marked falling in of one side of the chest is often seen. The shrinkage of the affected side is made more obvious by contrast with the compensatory hypertrophy of the sound lung, which makes the sound side unusually full and prominent.
Prominence of One Side of the Chest. In pneumothorax or pleural effusions, and sometimes in malignant disease of the lung or pleura, there is a marked increase in the size of the affected side of the chest. Rarely, emphysema may affect one lung predominantly. In pneumothorax or pleuritic effusion, we usually see, in addition to the above, enlargement of the affected side, a smoothing out of the intercostal depressions so that the surface of that side is much more uniform than the other side. Bulging of specific interspaces from great pressure within the chest rarely occurs.
Local Prominences. In nearly 25% of healthy chests, that part of the thoracic wall which overlies the heart (precordial region) is abnormally prominent. The cause of this condition is disputed. A similar prominence may be brought about in children (whose thoracic bones are very flexible) and occasionally in older patients by the outward pressure of an enlarged heart or an effusion in the pericardial sac. The prominence due to spinal curvature has been mentioned.
Less common causes of local prominence are:(1) aneurysm of the arch of the aorta;
(2) tumor of the chest wall, lung, or mediastinum, or of thoracic glands pressing their way outward;
(3) "cold abscess" (tuberculosis, actinomycosis) of a rib or the sternum; and
(4) empyema perforating the chest wall, the so-called empyema necessitatis.The Interspaces. Note retraction or bulging of interspaces. Retraction noted on inspiration points toward some obstruction to the free inflow of air in the respiratory tract. The first suspicion in unilateral retraction is rib fracture. Bulging may occur with massive pleural effusion, tension pneumothorax, and frequently is seen during the forced inspiration of the emphysematous or asthmatic patient. Bulging may be observed occasionally in the chest wall as the result of tumor, aortic aneurysm, or marked cardiac enlargement in infancy and childhood.
Prominent Scapulae. This condition is usually due to (1) lateral curvature of the spine or (2) serratus paralysis that is recognized by the startling prominence of the scapula if the patient pushes forward with both hands against resistance, resulting in "angel-wing" scapulae. In congenital syphilis, the medial borders of the scapulae are sometimes markedly concave and called scaphoid scapulae.
Trigger Points
Trigger points are often found in the serratus anterior, pectoralis major and pectoralis minor, sternalis, subscapularis, and scalene muscles. See Figures 17.3, 17.4, and 17.5.
Scoliotic Curves
Objective data are often obtained by utilizing various instruments. See Figures 1.1, 1.3, 1.8, 1.10, 3.5, 3.8, 3.9, and 3.16. Various roentgenographic methods can also be used to measure the degree of progressing or improving scoliotic curves such as the Risser-Ferguson method, the Cobb method, and the White-Panjabi method. For a description of these methods, see Schafer RC: Clinical Biomechanics: Musculoskeletal Actions and Reactions.
Scoliosis
The term scoliosis refers to any combination of lateral curvature from a straight line with twisting of the spine when viewed from the front or the back. What is grossly viewed in the typical scoliosis from the posterior are the typical spinal curves normally seen from the lateral. That is, the curves are situated in the wrong plane, frontal rather than sagittal, and the vertical axis rotation is usually in the wrong direction and often exaggerated. Simply, it is often as if the spine were fixed in space and the head and pelvis were rotated +/- several degrees in the same direction (refer to Fig. 1.6). Thus, the majority of the distortion seen in scoliosis is the result of rotation (Fig. 17.60). This is the gross effect of scoliosis. The segmental effect is abnormal focal motion-unit disrelationship where normal rotation, lateral tilting, and A—P facet slip has become fixed, functionally and/or structurally. Scoliosis is a mechanical disorder when gross, but there are always many biologic influences operating as well as purely mechanical forces.General Considerations. When a postural distortion is recognized, several clinical questions arise. For example, how severe is the distortion? Is it affecting function? Is the distortion stabilized or progressing? What was the initial cause or causes: congenital, pathologic, acquired, or a combination of factors? Can it be corrected? If so, how? How much correction can be expected? How long will it take? How much patient cooperation will be necessary?
The first step in answering these questions is a thorough physical examination. In slight or doubtful cases, the tips of the spinous processes should be marked with a marking pencil which makes the deviation more readily visible. It is assumed here that the postural analysis will follow a complete case history and standard physical, neurologic, and orthopedic examinations. Joint motion, muscle strength, sensory perception, and reflexes must be thoroughly evaluated.
Terminology. A great variety of terms are used in describing the various types of spinal distortion. In each case, however, scoliosis is described as if viewed from the posterior and exaggerated A—P curves are described as if seen from the side. See Table 17.12.
Scoliosis can be classified from a structural, functional, or clinical view point. In each classification, there is considerable overlapping and no single classification offers answers to all questions. However, we will briefly mention these so that a better appreciation can be developed.
Structural Classification of Scoliosis
The various forms of scoliosis can be grouped into two major types (structural and nonstructural), and each has its subdivisions according to its major etiology.Nonstructural Scoliosis. A nonstructural scoliosis is the effect of gravitational forces and muscles and ligaments of asymmetrical integrity. It will straighten by voluntary effort or in the non-weight-bearing positions. Non-structural (functional) scolioses are not usually as progressive as structural scolioses. They can be of the postural, compensatory, or transient type. Postural scoliosis curves are slight, disappear in the Adams and recumbent positions, and usually are first noticed at about 12 years of age. Compensatory scoliosis is the typical result of a leg length defect where the pelvis dips down on the short side. Transient structural scoliosis may be of the sciatic, hysterical, or inflammatory type. Sciatic scoliosis is not a true scoliosis, but rather a functional antalgic adaptation to pain caused by nerve root pressure or irritation. Hysterical scoliosis, most rare, is a manifestation of organ language of psychic origin. Inflammatory scoliosis is the result of such processes as a perinephric (eg, psoas) abscess.
Structural Scoliosis. A structural scoliosis will not straighten with voluntary effort in a non-weight-bearing position. It is quite rigid and the result of osseous deformation or fixated soft-tissue changes of related discs, ligaments, muscles, and joint capsules. Structural scoliosis may be of the idiopathic, congenital (Fig. 17.61), neuromuscular, neurofibromatotic, mesenchymal, or traumatic type. Its most common overt sign is a lack of adequate compensatory secondary curvatures; that is, decompensation, where the head and neck are lateral to the base of support when viewed from the front or back.
There are two major types of structural curves:
Irreversible structural curves that exhibit gross structural asymmetry and/or anomalies. Deformation can be exhibited between, within, and/or around involved vertebrae. When this occurs, there are two problems: (a) the spinal curves are "out of plane" and (b) there is vertebral motion-unit deformation. The immediate structural defect may be osseous, in the soft tissues, or both.
Structural curves that are the result of possible reversible connective tissue changes such as ligament shortening or chronic muscular hypertonicity. This type is usually the first stage of the first type. It is not unusual for a curve to exhibit some degree of functional reduction but not complete reduction; that is, it may be both functional and structural.
Features: Certain generalities can be drawn bilaterally as scoliosis progresses:
On the side of concavity, the vertebral bodies rotate anteriorly, the ribs are closer together and projected backward, the intercostal spaces are reduced and the soft tissues are thickened and contracted, the disc spaces are thinned (wedged) and the nucleus shifts toward the opposite side, the vertebral pedicles and laminae shorten and thicken, the flank rib ilium distance is reduced, and the intrathoracic organs become compressed.
On the side of convexity, the vertebral bodies rotate posteriorly, the ribs are further apart and projected anteriorly, the intercostal spaces are widened and the soft tissues are stretched, the disc spaces are widened, the vertebral canal becomes narrowed, the flank rib ilium distance is increased, and the intrathoracic viscera become stretched.
Clinical Classification of Scoliosis
A more detailed classification of spinal distortions is appropriate for many clinicians. One is offered in Table 17.13 that is a composite that has been adapted from the data of several authorities.
Associated Pulmonary Impairment. Maximum breathing capacity is considered to be reduced in proportion to the degree of thoracic scoliosis present. According to Gucker's studies, gross rotary deformity appears to affect cardiopulmonary function to a greater extent than gross lateral deformity. Pulmonary impairment is not usually a priority concern unless the deformed rigid thoracic cage reaches a point that restricts the pulmonary volume and vital capacity adequate for the demand. This is not to say that restriction far below this threshold will not predispose the patient to numerous cardiorespiratory disorders even though there are no signs of obstructive pulmonary disease. As the spinal deformity increases, the heart is pushed inferior and traction is placed on its superior nerves and vessels. See Figure 17.62.
Arterial restriction in the lung fields leads to right ventricular hypertrophy. While the effects may be perceived by cardiac auscultation, its cause is almost impossible to detect on roentgenography. Cardiorespiratory failure is so slow in these cases that the distortion and its neuromuscular and neurovascular causes are rarely given the credit they deserve.
The reduced vital capacity in spinal deformity may not be due solely to mechanical restriction inasmuch as weakened thoracic and possibly abdominal muscles, costal fixations, thoracic venous and lymph flow restrictions, and portal pooling are invariably involved in scoliosis. Most of these nonmechanical influences can be attributed to subtle secondary sympathicotonia.
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