Treatment of pain syndrome of the thoracic spine in children and adolescents using botulinum toxin under optical topography and electron control

What are spinal exostoses?

The bones of the spine account for less than 5% of all cases of osteochondromas, since they often form in the metaphyses of long tubular bones. Among all the bones of the spine, it is the processes of the vertebrae that are most often affected. In 50% of cases, exostoses are found in the cervical region, especially on the second cervical vertebra (C2). Less commonly, they form in the thoracic vertebrae (usually in the 8th and 4th). Only in isolated cases are osteochondromas diagnosed in the lumbar spine and sacrum.

Osteochondroma should not be confused with marginal exostosis of the vertebra, which occurs as a result of degenerative changes and the development of spondylosis. In the latter case, bone growths form along the edge of the vertebral body against the background of progression of osteochondrosis and are osteophytes. While osteochondroma most often forms on the vertebral arch and processes and is a continuation of the maternal bone, and not a growth on it.

Spinal exostosis may be the only one in the body or just one of many. In the latter case, they speak of multiple exostotic disease, which is usually diagnosed before 5 years of age.

Single neoplasms can occur as a result of trauma, hereditary predisposition, exposure to ionizing radiation, or in the absence of any of the above factors. In the latter case, they speak of the idiopathic development of osteochondroma, which occurs most often.

Basically, osteochondral exostoses are typical for children. But since they can manifest themselves for a long time, and also form as a result of injuries, the disease can be first diagnosed in adulthood. As a rule, osteochondromas are detected between the ages of 10 and 30.

Spinal osteochondropathy: causes, diagnosis, treatment

The formation of the disease occurs in adolescence (from 11 to 18 years). In the first stages, it is quite difficult to identify it, since osteochondropathy does not manifest itself in any way. But if it is possible to diagnose it in a timely manner, after completing a course of special medical therapy, the disease is completely cured, and the growth of bone structures stops.

Features of the pathology

As a rule, the disease occurs in the thoracic spine. There are rare cases when it is observed in the cervical or lumbar region. Osteochondropathy is the destruction of the vertebrae or intervertebral discs. The disease is divided into types:

1. Chondropathic kyphosis is the development of an inflammatory process in muscle tissue at the point of contact with the vertebral bodies, resulting in deformation of the latter to a “wedge” shape. This causes the spine to curve, leading to kyphosis.
2. Chondropathy or “Calvet's disease” is a process of destruction within the vertebral body, during which the vertebrae become wider and decrease in length. A process appears, at the site of which pain occurs when exposed to external influences.
3. “Krümmel’s disease” or inflammation in the body that forms as a result of suffering severe trauma. In this case, the vertebrae are deformed, and there is a curvature of the spine
   in the posterior direction.

Causes of pathology

The death or destruction of bone tissue can be the result of a disruption in its blood supply, provoked by the following factors:

• Genetic predisposition;
• Changes in hormonal levels;
• Infectious diseases;
• Calcium and some vitamins cease to be absorbed;
• Congenital diseases of the musculoskeletal system;
• Hemocirculation disorders;
• Frequent microtraumas of the spinal column;
• High physical loads on the back, in particular on the spine.

Diagnosis of osteochondropathy

To avoid serious consequences, it is necessary to diagnose the pathology in the early stages, which is quite difficult to do, but is possible with the help of an X-ray examination or MRI. In addition, you should pay attention to the child’s behavior:

1. There are complaints of unexpressed pain, which usually stops after rest.
2. Rapid muscle fatigue, weakness, the appearance of asymmetry.
3. As the disease progresses, the pain becomes more intense.
4. There is a change in the shape of the spine, which leads to the destruction of bone tissue.
5. The appearance of a tubercle or process at the site of damage to the vertebral bodies.
6. It becomes difficult to tilt your body or head forward.
7. At the last stage of pathology development, deformation of the chest occurs.

Treatment of the disease

As a result of untimely diagnosis of osteochondropathy, complications arise, the most common of which are kyphosis, spinal displacement and flat back. Middle-aged people may develop osteochondrosis. As a result of tissue death, the risk of fractures increases, so it is very important to consult a doctor immediately after the appearance of at least one of the syndromes.

The main goals of treatment therapy are:

1. Relief from pain.
2. Correction of posture and return of the vertebrae to their original position.
3. Reducing the risk of osteochondrosis and other complications.
4. Restoring the proper functioning of the intervertebral discs, vertebrae and body mobility (in case of difficulties when bending the head and body forward).

Correcting posture and restoring the proper functioning of the vertebral bodies are the most important goals in the treatment of osteochondropathy.

Therapeutic therapy completely excludes strong physical activity (including exercise therapy), physiotherapy, massage in any form, and taking medications not prescribed by a doctor. Sometimes bed rest on a hard surface is prescribed. If there is severe pain and a change in the shape of the vertebrae, a traction procedure with a load is performed on a beveled surface or under water. A prerequisite for treatment is adherence to a proper diet prescribed by a doctor and including foods high in vitamins A and B and calcium.

It happens that patients come with an advanced disease, when the process of developing complications has already started or there are pronounced changes in the spine. In such a case, surgical intervention cannot be avoided.

With osteochondropathy, the patient experiences various types of pain. In addition, the disease involves the destruction of bone tissue. To relieve a person from unpleasant sensations, medications are prescribed:

• Analgesics;
• Vasodilators;
• Multivitamin preparations based on calcium;
• Medicines that help restore intestinal microflora and absorb microelements from consumed foods.

Strong physical activity should be completely avoided. This condition especially applies to jumping in any form and lifting heavy objects. If there is no pain, a set of special therapeutic exercises is prescribed with a gradual increase in repetitions and a frequency of up to 3 times a day. An effective exercise for all patients is walking with a reclining stick located at the level of the thoracic spine. You need to grab it from behind with bent elbows.

The remaining physical exercises included in the treatment complex are developed individually together with the doctor, based on the person’s condition and taking into account the characteristics of the course of osteochondropathy.
Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Symptoms and complications

In most cases, vertebral exostosis is asymptomatic. If it forms along the back of the arch, over time a firm, usually painless lump may form on the neck or back. As the formation grows, the protrusion also increases in size and can cause discomfort. Sometimes this is associated with:

• swelling of soft tissues;
• redness of the skin;
• local temperature increase;
• pain when bending or turning the body, after prolonged sitting or physical labor.

You should consult a doctor as soon as possible if you experience persistent, intensifying pain, which may be in the nature of a lumbago. This may indicate damage to the spinal roots or even spinal stenosis. This can also be manifested by the appearance of sensory disturbances and limitation of movement, up to paralysis of those parts of the body for the innervation of which the strangulated segment of the spinal cord or the nerve root extending from it is responsible. Neurological disorders are observed in 20% of patients.

Exostosis can also mechanically compress nearby blood vessels. If it forms in the cervical region, it may be accompanied by:

• dizziness;
• tinnitus;
• headaches;
• loss of consciousness.

In addition to neurological and vascular complications, osteochondroma can provoke vertebral deformation, which will entail a chain of pathological changes in adjacent spinal motion segments. Also, the possibility of a fracture of the leg of the exostosis cannot be excluded, although when localized in the spine, this is rarely observed, mainly only with mechanical trauma. A spinal fracture is extremely rare.

The most dangerous complication of osteochondroma is degeneration into chondrosarcoma, which is more typical for multiple exostosis disease.

Osteochondropathy of the apophyses of the vertebral bodies[edit | edit code]

Osteochondropathy of the apophyses of the vertebral bodies

(aseptic necrosis of the apophyses of the vertebral bodies, or Scheuermann-May disease, Schmorl disease, osteochondropathy kyphosis, juvenile kyphosis) are more common in young men during the period of growth of the body at the age of 11-18 years. The disease was first described in 1921 by orthopedist Scheuermann, pathologist Schmorl and surgeon May.

The basis of spinal osteochondropathy is considered to be congenital inferiority of the discs and insufficient strength of the endplates of the vertebral bodies. The influence of hormonal factors is noted (the disease is often combined with endocrine disorders), as well as hereditary predisposition (possibly autosomal dominant inheritance). In the progression of deformity, the load factor plays an important role (improper mode, long sitting in a bent position, heavy physical work, carrying loads on the back).

As X-ray studies of a normal spine show, at the age of 10-12 years, additional apophyseal points of ossification of the vertebral body appear in the intervertebral cartilaginous discs, having a triangular shape on a radiograph in a lateral projection. The process of their bone fusion begins at the age of 14-15 years, and ends at 18-20 years. As a result, the vertebral body changes from a biconvex shape, characteristic of childhood, to a biconcave shape, which is characteristic of an adult.

Disruption of enchondral ossification in the area of ​​growth zones of the vertebral bodies (apophyseal zones) in Scheuermann-May disease leads to their wedge-shaped deformation and the formation of kyphosis. Most often, 3-4 middle or lower thoracic vertebrae are affected; localization of the process in the lumbar spine is quite rare. The most typical involvement in the pathological process is the VII, VIII, IX and X thoracic vertebrae.

Among all diseases of the spine, osteochondropathy is the most common, but due to its asymptomatic and painless course, it is not always diagnosed.

The development of spinal osteochondropathy is divided into levels, stages and severity. The osteochondropathy process is characterized by typical localization in the thoracic region (58.6%), less often in the thoracolumbar (18.2%) and lumbar (17.8%). In 5.4% of children the process is widespread. The disease is rare in the cervical spine.

During osteochondropathy, three stages are distinguished depending on age. Stage I, the initial stage, is considered to occur during the immature period of the spine. Stage II, blooming, as occurring at the beginning of ossification of the apophyses of the vertebral bodies and intensive growth of the spine. Stage III, the final one, as corresponding to synostosis of the apophyses of the vertebral bodies.

Residual signs of osteochondropathy persist for up to 30-50 years. Osteochondrosis often develops against their background.

The severity of spinal osteochondropathy is determined by:

• prevalence, i.e. the number of affected vertebral segments;
• the severity of cardinal signs (severity of deformation of the vertebral bodies, degree of narrowing of the discs, the presence of single and multiple anterior and posterior Schmorl's hernias);
• the presence, as well as the severity of pain in the spine and secondary membrane-radicular syndrome;
• the degree of limitation of function and decompensation of the spine, determined by the deviation of the body to the side and back.

In children and adolescents, three degrees of severity of osteochondropathy have been identified, depending on the severity of the above symptoms.

Clinical picture[edit | edit code]

The disease develops slowly and goes through three stages over the course of a number of years. The clinical picture of spinal osteochondropathy depends on the child’s age, stage and severity of the pathological process. The earliest sign of osteochondropathy is considered to be pathological posture, and the most characteristic symptom is kyphotic deformity of the spine. However, the transition of pathological posture to kyphosis was not noted. Fixed kyphosis occurs in no more than 50% of cases of Scheuermann-May disease, and severe kyphosis in only 5%.

Most often and early (from 5-6 years old) in children with spinal osteochondropathy, asymmetry of the shoulder girdles, shoulder blades, lines and triangles of the waist, paravertebral asymmetry, which (unlike dysplastic scoliosis) is unilateral, is determined. In the initial stage, protruding spinous processes are identified at the level of pathological changes, the palpation of which is painful.

Early on, a restriction in forward body tilt can be observed. Stage I continues until ossification of the apophyses of the vertebral bodies occurs and is characterized by slightly increased thoracic kyphosis

In stage II of the process, approximately half of the patients develop kyphosis. Its formation is accompanied by increased lordosis in the cervical and lumbar regions, and scoliosis can also form at the same time. The deformation becomes fixed. The addition of radicular syndrome of discogenic origin leads to even greater limitation of spinal mobility. Severe forms of kyphosis occur in no more than 5% of children. In 15% of children with spinal osteochondropathy, a flat back is formed, and in 34%, the physiological curves of the spine remain within normal limits.

In stages II and III of spinal osteochondropathy, children and adolescents often report a feeling of fatigue in the back and pain in the spine, as well as in the lower extremities. These symptoms are mild and unstable. After a night's rest they usually disappear.

In stage I, but more often in II and III, a weakly positive Lasegue symptom is determined, less often - Wasserman, shell symptoms, which are combined with a limitation in tilting the body forward and, perhaps, serve as the cause of such a limitation.

There is a group of adolescents with stage II (usually III) of the disease with more constant pain in the lumbosacral region, which, as a rule, is accompanied by radicular syndrome, often occurs for no apparent reason and often disappears without treatment.

X-ray examination[edit | edit code]

X-ray examination provides a reliable diagnosis of spinal osteochondropathy only in stage II of the process.

In stage I of osteochondropathy, there are no cardinal signs, but indirect signs may occur. These include:

• projection narrowing of discs on a frontal radiograph;
• unilateral rotation of the vertebrae in the thoracic and lumbar region;
• slight wedge-shaped deformation of the vertebrae at the level of developing pathological kyphosis;
• flattening of the vertebral bodies with an increase in their dorsoventral size;
• narrowing of the discs in comparison with those above and below them.

When ossification nuclei of the apophyses of the vertebral bodies appear (from 7-8 years), all the signs characteristic of osteochondropathy are determined:

• wedge-shaped deformation of the vertebral bodies, flattening and increase in their dorsoventral size;
• massive lumbar vertebrae;
• violation of the integrity of the endplate;
• narrowing of the intervertebral spaces, uniform or only in the posterior sections;
• anterior and posterior, single or multiple Schmorl's hernias. Variable and rarer signs include marginal fracture of the bodies (usually lumbar vertebrae), disc calcification, retrolisthesis and spondylolisthesis.

After synostosis of the apophyses with the vertebral bodies, the wedge-shaped deformation decreases, due to which in stage III kyphosis and scoliosis decrease somewhat.

Treatment[edit | edit code]

They recommend general strengthening treatment, vitamin therapy, a rational regime of work and rest (sleeping on a hard surface), developing correct posture, and unloading the spine. In order to strengthen the muscle corset, therapeutic exercises, swimming in the pool, and massage of the back muscles are prescribed. Some authors recommend wearing a corset with a pelot at the apex of the deformity in the position of extension of the spinal column. With early treatment, it is possible to stop the development of the process and the formation of severe deformation. In isolated cases, with severe kyphosis with neurological symptoms, surgical treatment is indicated.

Admission to sports is prohibited.

Diagnostics

The appearance of a protrusion on the back or other symptoms of osteochondroma is a reason to consult an orthopedic traumatologist. The main method for diagnosing spinal exostoses is x-ray. In the resulting photographs they have the appearance of a “cauliflower” located on a wide base or thin stalk. The cortical walls and medullary space of the neoplasm are a direct continuation of those of the maternal bone. It reveals a funnel-shaped expansion of the cortical walls. The cartilaginous cap may not be visualized on x-ray in the absence of foci of mineralization.

Spinal exostoses are often discovered accidentally during an examination to diagnose osteochondrosis, protrusions and intervertebral hernias.

To differentiate osteochondroma from other types of neoplasms, CT and MRI may be additionally prescribed. The latter method allows you to examine the cartilage cap and accurately determine its size, which is important for assessing the risk of malignancy. A dangerous sign from this point of view is the width of the cartilaginous layer of exostosis more than 1.5-2 cm. MRI also makes it possible to assess the condition of adjacent structures: intervertebral discs, spinal cord, blood vessels and nerves.

CT is used to assess the degree of mineralization of the neoplasm. It also allows us to confirm its direct connection with the medullary space of the maternal bone.

Osteochondropathy of the vertebral body[edit | edit code]

Osteochondropathy of the vertebral body

(Calvet's disease, flat vertebra) was first described by J. Calve in 1925. This disease is not considered rare, and according to some data, among tumor and dysplastic processes in the spine in children and adolescents, it accounted for 20%. The pathology is based on aseptic necrosis of the spongy substance of the vertebral body. The duration of the disease is from 2 to 5-6 years. Flat vertebrae are more common in boys aged 3 to 16 years; mainly, at the age of 7-14 years, the thoracic vertebrae are most often affected, then the lumbar and cervical vertebrae. More than half have multiple eosinophilosis.

Clinical picture[edit | edit code]

Early symptoms of the disease include fatigue in the back, radiating pain or pain in the spine, which may first appear at the moment of jumping or somersaulting over the head. In these cases, pain may be a consequence of a pathological fracture of the vertebral body.

When palpating the spinous processes, tenderness and button-like protrusion of the spinous process of the affected vertebra are determined. Trunk bending and extension may be limited, and radicular and spinal symptoms may occur. Sometimes the disease begins with a rise in temperature to 39? C. Blood tests determine increased ESR and eosinophilia.

X-ray examination[edit | edit code]

Diagnosis is based primarily on the results of X-ray examinations.

On a profile X-ray, the affected vertebra is compacted, evenly flattened and expanded in the anteroposterior direction (platybrachyspondyly). The vertebral body takes on the appearance of a narrow strip, its anterior edge protrudes anteriorly, and the intervertebral spaces are widened.

Treatment[edit | edit code]

The basis of treatment is unloading of the spinal column (bed rest on the back on a hard bed or in a plaster bed with a reclinating cushion under the affected vertebra) and therapeutic exercises. Lying down, massage, general and therapeutic exercises are performed, aimed at reclinating the flattened vertebra and strengthening the back muscles (creating a muscle corset). During the recovery stage, it is recommended to wear a removable orthopedic corset that relieves stress on the spinal column. Some authors consider it advisable to perform posterior spinal fusion in order to stabilize the spine and quickly verticalize (lift to a vertical position) the patient.

Athletes at particular risk are boys aged 3 to 16 years (mainly from 7 to 14 years old) who engage in acrobatics, artistic gymnastics, weightlifting, martial arts, jumping, and team sports.

Admission to sports is prohibited.

Treatment of spinal exostosis

The only effective way to treat osteochondroma is surgery. It is carried out if there are clear indications. This:

• rapid growth of the tumor, detection of signs of malignancy during diagnostic studies;
• threat of spinal cord compression;
• vertebral fracture or pedicle osteochondroma;
• development of neurological or vascular complications;
• persistent pain.

If the benign nature of the neoplasm is confirmed and it does not provoke any changes in well-being, dynamic monitoring of it is sufficient. But if, during control X-rays, rapid growth of the tumor is observed, the question of its removal is raised.

In most cases, marginal bone resection is used. The operation is performed under general anesthesia and involves gaining access to the tumor through a small soft tissue incision in its projection. After this, it is removed using special surgical instruments within healthy tissue. It is important to remove all osteochondral growth. The wound is then sutured and covered with a sterile dressing.

For massive formations and when they are located in hard-to-reach places, decompressive laminectomy is sometimes performed. The operation involves removal of spinal exostosis along with a fragment of the vertebral arch. To compensate for the resulting defect, allograft or artificial stabilizing systems can be used.

Resection of spinal exostosis leads to complete recovery in 89% of cases. Relapses of the disease are usually caused by incomplete removal of fragments of the tumor and its capsule.

Rehabilitation after surgery

After spinal surgery, the patient must remain in the hospital. The duration of hospitalization depends on the type of operation and the nature of the postoperative period. On average, discharge is carried out in 3-7 days. Patients are necessarily prescribed drug therapy, exercise therapy, and sometimes physiotherapy. It is also necessary to limit physical activity, especially when performing a laminectomy.

Thus, spinal exostoses are a rare but quite dangerous disease. It can be asymptomatic or can lead to dangerous complications. Therefore, if they are identified, you should immediately contact an orthopedic traumatologist to assess the degree of risk and select adequate treatment tactics.