د. رمضان جلال شمس الدين

What must be completed? It is important to realize that increased kyphosis can occur in children or adults.

Treatment options vary depending on the age of the patient and the cause of kyphosis. Surgery may be needed to treat some types of kyphosis. However, non-surgical methods are more common. Non-surgical monitoring of postural kyphosis, skeletal kyphosis of small size in developing patients, and even kyphosis large in patients who have completed their growth is usually recommended. Patients will return to see the surgeon periodically for an examination and x-rays to ensure that the kyphosis is not worsening. Children may need x-rays every 6-12 months as they grow, but adults can usually observe kyphosis less often. Exercise and physical therapy If the patient has pain or increased kyphosis, physical therapy or an exercise program may be recommended. A physical therapy program often includes stretching and strengthening exercises performed with a physical therapist or alone at home. The goal of physical therapy is to help improve posture and make the spine stronger and more flexible. Kyphosis exercises focus on strengthening the muscles that support the spine.

Although exercises and physical therapy are not expected to correct skeletal kyphosis, they often help a patient with back pain by strengthening the back muscles. Stents In the structural form of kyphosis called Scheuermann's kyphosis, a stent treatment may be recommended. Physical therapy or an exercise program may be recommended. A physical therapy program often includes stretching and strengthening exercises performed with a physical therapist or alone at home. The goal of physical therapy is to help improve posture and make the spine stronger and more flexible.

The subgroup of patients who would benefit from wearing a brace usually includes those who are still developing, have moderate-sized kyphosis, have a body type that is tolerant of brace wear and are willing to comply with brace use. The protocols for strengthening kyphosis, including the type of brace to be used, the number of hours per day to wear the brace, and the number of months or years of use required are variable and will be determined by your surgeon. Braces should be regularly evaluated and adjusted to ensure proper fit.

Surgical treatment may be recommended for some cases of kyphosis, especially if the curvature is significant, worsening, or associated with back pain. Surgery can provide significant correction without the need for a postoperative brace. The main benefit of the operation is to correct the shape of the back. Pain relief after surgery is uncertain, but many patients experience less pain after they recover from surgery. Most surgeries are performed through an incision in the back. However, in severe cases, some doctors may recommend additional surgery on the front of the spine. how about

Brace wear Those who are still developing, have moderate-sized kyphosis, have a brace-tolerant body type and are willing to comply with brace use. The protocols for strengthening kyphosis, including the type of brace to be used, the number of hours per day to wear the brace, and the number of months or years of use required are variable and will be determined by your surgeon. Braces should be regularly evaluated and adjusted to ensure proper fit.
Surgical treatment may be recommended for some cases of kyphosis, especially if the curvature is significant, worsening, or associated with back pain. Surgery can provide significant correction without the need for a postoperative brace. The main benefit of the operation is to correct the shape of the back. Pain relief after surgery is uncertain, but many patients experience less pain after they recover from surgery. Most surgeries are performed through an incision in the back. However, in severe cases, some doctors may recommend additional surgery on the front of the spine. Patients are usually able to return to all activities after surgery. Your surgeon will tell you how long your activities may be restricted after surgery.

Spinal osteotomy: Spinal osteotomy is a surgical technique used during some fusion surgeries for skeletal kyphosis. "Osteotomy" means making a cut in the bone. This means that parts of the vertebrae will be removed to create flexibility and allow the surgeon to move the spine into the correct position. In some cases, osteotomy may involve removing portions of the ribs. Because osteotomy often carries a greater risk of injury to the spinal cord, blood vessels, and nerves, it is only performed when needed to achieve a correction that cannot be done by other methods.
Aim of surgery: The goal of surgery is to fuse the spine into a corrected position, while preserving the integrity of the nerves and spinal cord. There are always risks associated with any surgery. These matters should be discussed with your surgeon.
Some important points when considering surgery are: 1. Thorough discussion before surgery with your treating doctors 2. Good nutritional status before and after surgery 3. Exercise program before and after surgery 4. Positive mental attitude.

Do nutritional factors cause kyphosis?
What you eat does not appear to cause kyphosis in otherwise healthy young adults. If you are older, osteoporosis, or weak bones, can result from not having enough calcium in your bones and can cause kyphosis. It is helpful to discuss with your doctor how to maintain bone strength as you age.
Does poor posture cause structural or structural kyphosis?
The exact cause of Scheuermann's kyphosis is unknown, but there is no evidence that poor posture does not cause kyphosis or permanently change the bones of the spine.
Can carrying a heavy book bag cause kyphosis?
Heavy back packs and loads on the back do not cause permanent changes in the bones of the spine or kyphosis. Although lifting heavy objects can certainly contribute to back muscle pain, it does not change the shape of the spine.
Does kyphosis cause back pain?
The back muscles of a person with kyphosis have to work harder while sitting and standing and can become sore when tired. The bones themselves are not a cause of pain. Increased kyphosis makes you more likely to develop osteoarthritis of the spine as you age.
Does smoking cause kyphosis?
Smoking does not cause kyphosis. Smoking makes spine surgery less safe for the patient and can actually prevent bone and soft tissue healing after surgery.
Do metal implants rust or are rejected by the body?
Modern metal spine implants do not rust, and usually do not need replacement, unless the patient is experiencing complications from surgery. Some patients may have sensitivity to metals as the body reacts to the type of metal. If a person is allergic to certain metals, different metals may be used during surgery.
Does spine surgery interfere with normal childbearing?
Spine surgery generally does not interfere with childbearing, unless surgery involves the pelvis. In this case, the impact of surgery on pregnancy can be discussed with your surgeon.
Is kyphosis contagious?
Kyphosis is not contagious and cannot be passed from person to person like the common cold. Some cases of kyphosis can be hereditary and run in families. However, we do not understand the genes well enough to know who will develop vertebral malformation in the family.

Lumbar herniated disc and lower back pain
Low back pain is one of the most common disorders affecting the musculoskeletal system and is considered the most prevalent in the modern era. It still poses a real health challenge in terms of prevention and treatment, and it ranks third in terms of the high cost of treatment after cardiovascular diseases and cancerous diseases.
The spine is the only longitudinal axis of the body that bears the entire weight of the trunk, and its lumbar vertebrae are connected with the pelvis and its movement with the sacral vertebrae, and accordingly, any imbalance that affects the body axis (functionally or anatomically) will negatively affect the functional level of the trunk and the movement of the body in general and thus It may reduce psychological, economic and social efficiency, especially when pain appears, which greatly affects the daily activities of the individual and the quality of life he lives. In dispersing the forces acting on it by distributing pressure on the nucleus of the cartilaginous disc, which distributes it equally on the surrounding cartilage rings in all directions over the entire area of the cartilaginous disc. The vertebral congruence condition becomes lost.
Low back pain is usually divided in terms of recurrence into acute, which occurs suddenly and often occurs once or twice in life, and chronic, which occurs frequently, cumulatively and with a higher level of severity with each time.
It is divided in terms of the type of cause into specific mechanical pain, which is directly related to the pain that results from acute muscle strain and herniated disc, which is responsible for 90% of these cases, and to non-mechanical, non-specific pain, which is indirectly related to the pain that results from anxiety states, enlargement of the prostate gland, and dryness. Herniated disc. In terms of the degree of pain, it is divided into simple, medium and severe pain.
A herniated disc (herniated disc or lumbar disc herniation) is defined as the nucleus and its rings being pushed irregularly from between the vertebrae to the back under the influence of severe pressure with the occurrence of a hernia in the cover of the cartilaginous rings, to grow towards the back to enter the spinal canal and put pressure on the spinal cord. This is called this The condition of the central compressive cartilage. Either it grows backward and to one side and presses on one of the nerve roots branching from the spinal cord. This condition is called the noncentral or lateral compressive cartilage. Regardless of the type of herniated disc or herniated disc in the lumbar disc, it causes severe defensive muscle contractions.
The range of motion between the vertebrae is reduced, in addition to the occurrence of severe pain, and the level of danger is high, as in road accidents, for example, where the pressure is very strong to cause a cartilage rupture with sharp ends that threaten to tear and injure the surrounding tissues and nerves during movement, causing partial or total paralysis of the nerve depending on the force of pressure The severity of the injury to the nerve root.
The most frequent cases are in the lumbar region between the fourth and fifth lumbar vertebrae and between the fifth lumbar and first sacral vertebrae.
Often, these patients complain of a group of severe neurological disorders represented by sensory impairment and disturbance in
The level of the reflex reaction, weakness in the muscular ability of the lower extremities or one of them, and severe pain in the direction responsible for the nerve root compressed in the herniated disc, which makes this disease a major cause to change the nature of the patient’s psychological, social, economic and family life, especially when it causes any degree of partial or partial disability. total
As for recurrent chronic cases, it is accompanied by a group of functional and anatomical changes on the lower back before the injury of a herniated disc, such as the occurrence of simple long-term muscle tension for many reasons. The cartilage disc reduces the concentration of water in that part of the cartilage, as water - despite its low concentration in the cartilage - plays an essential role in the process of distributing and spreading nutrients within the tissue of the lumbar disc and the speed of completion of vital reactions. With the persistence of muscle tension and the passage of time, this condition is called degenerative lumbar disc dehydration
Then begins a process of functional changes at the level, slowing down the speed of biochemical reactions, as well as anatomical changes in the formation of the lumbar disc, such as a lack of cartilage tissue cohesion and weakness in its elasticity and a decrease in the size and mass of the lumbar disc, so it becomes less able to absorb the forces acting on it, and the process of fibrosis of the spinal canal begins. The nerve roots exits increasingly over time to cause what is known as neural tube stenosis.
This results in sharp pains in the lower back extending to the lower extremities or one of them, with lethargy and weakness and a decrease in the ability to walk because of this, and the ability to straighten the trunk is weakened due to the contact of the cartilaginous protrusion with the nerve roots emerging from the spinal cord.

Most cases of herniated discs of the lumbar disc usually occur between the ages of twenty and forty, with most injuries occurring.
Due to improper lifting of heavy weights or injuries resulting from practicing some sports such as weightlifting and gymnastics, or for former athletes in some sports.
Herniated disc pain is treated medically
With it on the basis of removing the pressure from the cartilage of the cartilage
On the nerves by using the abduction tension
(slitting the vertebrae apart) naturally using positions
body (positional therapy) called stretching

scoliosis
Scoliosis is a three-dimensional deformity of the spine and rib cage. It may develop as a single primary curve (looks like the letter C) or as two curves (a primary curve with a compensating secondary curve forming an S shape). Scoliosis may occur only in the upper back (thoracic) or lower back (lumbar), but it most commonly develops in the area between the thoracic and lumbar (the thoracic and lumbar areas). The doctor attempts to identify scoliosis by the shape, location, direction and size of the curve and, if possible, the cause. The severity of scoliosis is determined by the extent of the curvature of the spine and the angle of rotation of the trunk.
Determining and classifying the type of scoliosis often by the shape of the curve, by its location, or by its direction:
Scoliosis is classified according to the shape of the curve into structural (in other words true organic) or non-structural (which is functional or secondary). • In structural scoliosis, not only do the spine bend from side to side, but the vertebrae also rotate, resulting in a twisting of the spine . During torsion, one side of the rib cage is pushed out so that the spaces between the ribs widen and the shoulder blade protrudes (which causes the rib cage to deform or protrude); The other half of the rib cage is twisted inward, putting pressure on the ribs. • The non-structural or functional curve does not twist, but is a simple curve from side to side, and it is usually a compensation for the main structural curve or due to muscle spasms or other diseases of the vertebrae.
Determine scoliosis by its location. The location of the skeletal curve is determined by the location of the apical vertebra, which is the protruding vertebra at the apex (the highest point) of the spinal tuberosity. This particular paragraph will also undergo severe rotation.
Definition of scoliosis according to its direction. The direction of the curve in structural scoliosis is determined by whether the convex (rounded) side of the curve curves to the right or left. For example, a doctor defines a specific condition as right thoracic scoliosis if the apical vertebra is in the thoracic region (upper back) of the spine and the curvature is to the right.
The size of the curve is determined by taking length and angle measurements of the curve in an X-ray view.

Causes of scoliosis
First: idiopathic scoliosis
In 80% of patients, the cause of scoliosis is unknown. These conditions are called idiopathic scoliosis. Most cases of idiopathic scoliosis have a genetic basis, but researchers have not yet identified the gene or genes responsible for it. Researchers are investigating potential physical abnormalities that may cause bone or muscle imbalances that can lead to scoliosis. Among them are the following: muscles around the vertebrae. Some research suggests that imbalances in the muscles around the vertebrae may make children susceptible to spinal deformities as they grow. High arches in the feet. One study showed a higher incidence of abnormally high arches in the feet of people with idiopathic scoliosis, suggesting that altered balance may be a factor in some cases. Coordination problems. Some experts are looking at inherited impairments in cognition or coordination that may cause asymmetric spine development in some children with scoliosis. The investigators are also looking at possible abnormalities in collagen, an important structural protein found in muscle and bone. Other researchers are looking at a possible defective gene responsible for the production of fibrillin, an important component of the connective tissue that makes up bone and muscle. Some research has revealed abnormalities in a calcium-binding protein, calcodulin, among patients with scoliosis compared to the general population. Other researchers are still studying melatonin, a hormone secreted in the brain involved in sleep and growth. Animal studies and some human studies have found abnormalities associated with scoliosis.

Second: congenital scoliosis
Congenital scoliosis is caused by congenital abnormalities of the spine that usually involve abnormalities in the development of the vertebrae (missing or fused vertebrae). The condition usually appears around the age of two or between the ages of 8 and 13 as the spine begins to grow more rapidly, putting more stress on congenital malformations. Curves in such cases should be closely monitored, as they can progress rapidly. (Kidney problems, especially with only one kidney, often coincide with congenital scoliosis.)

Third: Scoliosis caused by genetic and medical disorders
Scoliosis may also be the result of muscle paralysis or deterioration from conditions such as myasthenia gravis, polio, or cerebral palsy. Other diseases that can cause scoliosis are Marfan syndrome, Friedreich's ataxia, Albers-Schönberg disease, rheumatoid arthritis, and osteogenesis imperfecta. Spinal cord injury may also cause scoliosis. A very rare genetic disease called familial dysautonomia has been identified as a cause of scoliosis in Jewish children of Ashkenazi descent. (It should be noted that only 500 cases have been reported globally, and this is related to the nature of the family composition of the Jews). Birth defects known to cause scoliosis include spina bifida or myelomeningocele (congenital hernia of the central nervous system).

Fourth: tumors of the vertebral column
Tumors and small growths or abnormalities in the spine may play a larger role than previously thought in the causes of scoliosis in young children. Back surgery to remove benign tumors increases the risk of spinal deformity.
Fifth: Causes of scoliosis other than structural or functional
Nonstructural scoliosis is sometimes caused by poor posture, leg length differences, and muscle spasms.

Scoliosis risk factors
General risk factors for idiopathic scoliosis. Idiopathic scoliosis (where the cause is unknown) is the most common form. It almost always occurs during a growth spurt just before and during adolescence. However, it can also occur in young children and even in infants. About 2% to 3% suffer from

Adolescents have a curvature of 10 degrees or more, but only about 0.3% to 0.5% have curves greater than 20 degrees. Mild curvature occurs equally in girls and boys, but curvature is 10 times more likely to occur in girls.
Medical risk factors. People with certain medical conditions that affect joints and muscles are more likely to develop scoliosis. About 10% of girls with Turner syndrome, a genetic disease common in women, develop scoliosis.
Young athletes. A 2000 study reported that young girls who did rhythmic gymnastics had a 10-fold greater risk of developing scoliosis. This elevated risk is likely due to three concurrent factors: an imbalance of weight on the spine, loose joints and a delayed onset of puberty. (Delayed menstruation is a common risk factor for all female competitive female athletes such as stress fractures and possibly scoliosis.)

Risk factors for the progression of curved scoliosis in affected children and adolescents
Once a mild curve is observed, the next step becomes more difficult, as it predicts whether or not the curve will progress to a more severe condition. Although as many as three in 100 teens have a condition that's serious enough to at least need observation, the likelihood of severity may be lower or above average depending on other factors.
• Being female or at a younger age at the onset of scoliosis increases your risk.
• The greater the bending angle, the greater the risk. At 20 degrees, only about 20% of the curves advance. However, young adults diagnosed with a 30 degree curve have a 60% risk of progression; With a 50 degree curve, the hazard is 90%.
• Girls who have low scoliosis and an unbalanced spine by more than an inch may be less likely to develop curves. Taller girls also appear to be at greater risk. Curvatures caused by congenital scoliosis (spine problems present at birth) may progress rapidly.
Risk factors for progression to scoliosis in adults
In rare cases, scoliosis may develop in adults who may have had unknown or untreated scoliosis in their youth. Osteoporosis or weak bones, a serious problem in many older adults, can cause mild curvatures to develop. (Osteoporosis itself is not a risk factor for the onset of new scoliosis.) However, in most cases, it is not known why adult curves progress.
How dangerous is scoliosis? Impact on the lungs and heart
The severity of scoliosis depends on the degree of curvature and whether it threatens vital organs, specifically the lungs and heart. Mild scoliosis effect (less than 20 degrees). Mild scoliosis is not serious and requires no treatment other than monitoring.
The effect of moderate scoliosis (between 25 and 70 degrees). It is still not clear if mild scoliosis causes major health problems. In one study, adults with mild scoliosis had normal lung function, although they had difficulty exercising.
The effect of severe scoliosis (more than 70 degrees). If the curvature exceeds 70 degrees, the severe twisting of the spine that occurs in skeletal scoliosis can cause the ribs to press on the lungs, restrict breathing and reduce oxygen levels. One study concluded that nearly two-thirds of patients with 90-degree curves and below had less than 80% of normal lung capacity. Abnormalities can also affect the heart and cause dangerous changes.
The effect of severe scoliosis (more than 100 degrees). Ultimately, if the curvature reaches more than 100 degrees, both the lungs and the heart can be injured. Patients with this level of risk are at risk of developing lung infections and pneumonia. Curves greater than 100 degrees increase the mortality rate, but this problem is very uncommon in America.
How is scoliosis diagnosed?
The severity of scoliosis and the need for treatment are determined by the extent of the curvature of the spine and the angle of rotation of the trunk (ATR). Both are measured in degrees. The two factors are usually related, so, for example, a person with a 20° spinal curve has a 5° ATR. This measurement used to be a standard for recommending treatment, although it is now known that up to 80% of 20° curves do not get worse. Scoliosis is diagnosed when the curve measures 11 degrees or more, but treatment is not usually required until the curve is 30 degrees and the ATR is 7 degrees.

physical examination
Forward bending test. A screening test often used in schools and in pediatric or primary care doctors' offices is called the forward bend test, in which the child bends forward with his arms hanging down, with feet together and knees straight. The curve of structural scoliosis is more pronounced when bending, and the examiner may notice an unbalanced rib cage, where one side is higher than the other, or other abnormalities. The forward bend test is not sensitive to deformities in the lower back, a very common site of scoliosis. Therefore, it misses about 15% of scoliosis cases, and many experts do not recommend this test as the only method for detecting scoliosis.
Other physical tests. The patient is usually asked to walk on the toes, then the heel, and then he is asked to jump up and down on one foot. These activities indicate leg strength and balance. The doctor will also check for tight tendons in the back of the leg, which is typical in adolescence, but may also indicate nerve root irritation or spondylolisthesis, a condition in which one vertebra slips forward over the other. The doctor will also check for nervous system dysfunction by testing reflexes, nerve sensation, and muscle function.
Recognize the curvature
Diagnosis

True is important, because poor judgment can lead to unnecessary X-rays and cumbersome treatments in children who are not at risk of progression. Unfortunately, although measurements of curves and rotation are useful, there is no test yet to determine whether or not a curve will advance. tilt (scoliometer). The clinometer (scoulometer) measures deformities of the trunk. The procedure is as follows:
The patient is asked to bend with outstretched arms and press the palms together, until a curve can be observed in the chest (upper back) area. The Scoliometer is placed on the back and is used to measure the apex (highest point) of the curve. Scoliometer results can indicate problems, and some experts believe it will be a useful tool for widespread screening. However, Scholetter's scales measure rib cage abnormalities in more than half of children who have been shown to have very little or no lateral curves. Scholetter's scales are not accurate enough to guide treatment, and if results show an abnormality, an X-ray should be performed.
Imaging tests
X-rays are currently the most cost-effective way to diagnose scoliosis. Experts hope that an accurate, non-invasive diagnostic technique can be developed that may eventually replace some of the X-rays currently used to monitor the progression of scoliosis. So far, some of these techniques appear to be fairly accurate for detecting scoliosis in the upper back (the thoracic region) but not scoliosis in the lower back (the woody region).
X ray. If the examination indicates scoliosis, the child may be sent to a specialist who takes an initial X-ray and monitors the child every few months with frequent X-rays. X-rays are necessary for the accurate diagnosis of scoliosis in several ways:
• X-rays reveal the degree and severity of scoliosis.
• An X-ray identifies any other abnormalities of the spine, including kyphosis (hunchback) and hyperlordosis (fluctuation).
• X-rays help the doctor determine whether the skeletal growth has reached maturity or not.
• X-rays of patients with curvature can help distinguish between structural and non-structural scoliosis.
Structural curves persist when a person bends, and non-structural curves tend to disappear. (It should be noted that sometimes muscle spasms or a growing spine can cause non-structural scoliosis, which shows a curve when bending.)
In children and adolescents with mild curvatures or in older adolescents with more severe curvatures, but whose growth has stopped or slowed, X-rays should be done every few months in order to detect the increased severity. Young adults with scoliosis should be sure to keep X-rays indefinitely in case back problems develop later in adulthood and need to be re-examined.
curve calculation
cup method. The degree of the curve is almost always calculated using a technique known as the Cobb method.
On an X-ray of the spine, the examiner draws two lines: one line that extends outward and upward from the upper vertebra edge of the curve. The second line extends outward and downward from the lower vertebrae. Then a vertical line is drawn between the two lines. The angle of intersection is measured to determine the degree of bending.
The Cobb method is limited because it cannot fully define the three dimensions of the spine. So they are not effective in determining spinal rotation or kyphosis. It also tends to overestimate the curve. Other diagnostic tools are needed to make a more accurate diagnosis.
A new technique that uses calculations based on geometric principles for the apex of the curve as well as the top and bottom of the curve to determine all dimensions of the curve may prove to be accurate.
Determine the end of growth
Even if the curve is calculated accurately, it is still difficult to predict whether or not scoliosis will progress. One way to predict whether or not the curvature will progress is to know when the child will stop growing. If a child has years to grow, the spine has more time to progress. If a child stops growing within a year, the progress should be very slight. (It should be noted, however, that some progression occurs in approximately 70% of the curves even after the spine has matured.)
Knowing a child's age is of course the first step in estimating the end of development. In addition, other methods have been developed to help predict the end of the growth phase.
One method is called the Risser's sign, which quantifies the amount of bone in the area at the top of the hip bone. A low score indicates that the skeleton still has significant growth; A high score means that the child has almost stopped growing and a small curve is unlikely to progress much further. The Rieser scale varies between genders and boys.
Scoliosis treatment has undergone significant changes over the past decade and a number of options are available.
treatment decision
The general rule for treating scoliosis is to monitor the condition if the curve is less than 20 degrees and consider treating curves greater than 25 degrees or those that progress by 10 degrees during monitoring. However, whether scoliosis is treated right away or just monitored is not an easy decision. The percentage of cases that will progress more than 5 degrees can be as low as 5% in certain cases and as high as 50% to 90% depending on severe curves or other predisposing factors:
• age. In general, the older the child, the less likely the curve will progress. Experts estimate that curves less than 19 degrees will progress by 10% in girls between the ages of 13 and 15 and 4% in children older than 15. (In some rare severe cases, the curvature may worsen even after treatment and the end of growth due to the pressure of body weight on the abnormal curvature.
• Gender. Girls are more likely to progress than boys.
• bending site

. Thoracic curves, those at the top of the spine, are more likely to develop from thoracolumbar curves or lumbar curves, those in the middle of the spine to the bottom.
• Intensity of bending. The higher the score, the more likely the lungs will be affected.
• The presence of other health conditions. Children in poor health may experience more stressful scoliosis treatments than other children. On the other hand, children with existing conditions that threaten lung and heart problems may need immediate and aggressive treatment.

Backbones
The spine is a column of small bones or vertebrae that support the entire upper body. The column is grouped into three sections of paragraphs:
• Cervical vertebrae (C) are the bones of the cervical spine and consist of seven vertebrae that support the neck and head.
• The thoracic vertebrae (T) are twelve spinal bones connected to the rib cage.
• The lumbar vertebrae (L) are the five lowest and largest bones in the spine. Most of the body weight and pressure falls on the lumbar vertebrae.
• At the bottom of the lumbar vertebrae lies the sacral vertebrae, which is a skeleton in the form of a shield that connects to the pelvis at the sacroiliac joints.
• At the end of the sacrum there are two to four small vertebrae partially fused known as the coccyx or "tail bone".

 
• Each paragraph can be identified using a letter and a number; The letter reflects the region (C = neck, T = chest, L = lower back, and S = sacrum), and the number indicates its location within that region. For example, C4 is the fourth lowest bone in the cervical vertebrae, and T8 is the eighth thoracic vertebra.

• The vertebrae in the spine are separated from each other by small cushions of cartilage known as intervertebral discs, known to people as vertebral cartilage. Inside each disc is a gel-like substance surrounded by a fibrous structure. The disc is 80% water, which makes it very flexible.
• Each vertebra in the spine contains a number of bony projections, known as processes. Spinal processes and transverse processes are connected to the muscles in the back and act like little levers, allowing the spine to twist or bend. The articular processes form the joints between the vertebrae themselves, they meet together and intertwine.
• Each vertebra and its processes surround and protect a central opening in the form of an arch. These arches, aligned down the spine, form the spinal canal, which surrounds the spinal cord, the central stem of the nerves that connect the brain to the rest of the body.
• The upper torso usually has a gentle external curve (kyphosis) while the lower back has a reverse internal curve (lordosis).

the pituitary gland
It is a very small gland located in the middle of the bottom of the skull, its diameter is not more than 1 cm and its weight is between 1/2 to 1 g
It is located in a small bony cavity known as the saddle above the sphenoid sinus at the bottom of the skull.

Before the twentieth century, it was prevalent among scientists that its function was to drain pituitary secretions from the brain through the nose.

With the beginning of the twentieth century, its role in hormonal control in the body was discovered, and after that, the discovery and separation of the hormones generated from it and its chemical composition and its role in controlling other tissues, organs or glands in the body.
In the middle of the twentieth century, the regulatory relationship of the so-called hypothalamus with the pituitary gland was discovered, and it was a new beginning to understand the movement of hormones in the body, and that all endocrine glands are linked to the pituitary gland and the pituitary gland is directly linked to the brain through what is known as the hypothalamus.

• What is the function of the hypothalamus?
• It secretes two groups of hormones, one of which stimulates the pituitary gland and the other inhibits it
• It also contains the bodies of neurons that control the posterior lobe of the pituitary gland

Which consists???????
It consists of two parts, the anterior lobe 2/3 of the pituitary gland, which is a glandular tissue that secretes hormones
Posterior lobe 1/3 of the pituitary gland It is a nervous tissue that contains nerve endings that transmit hormones.

• When a disorder occurs in the pituitary gland, it leads to a disorder of the body as a whole in one way or another, due to the loss of the balance that we talked about earlier.
• Syndrome known as menopause or disorder and increased milk secretion.
• Of course talking about the main or central cause associated with the pituitary gland.
• Because there are many reasons for the increase in the milk hormone leading to this pathological syndrome, known as peripheral causes. (Pregnancy, breastfeeding, medications, muscle stress, psychological disorder, laziness of the thyroid gland)

The central or main reason for the increase in the milk hormone is the increase in the size of the pituitary gland due to a benign tumor in it or the hypothalamus or any pressure on the arm that connects the hypothalamus to the pituitary gland.
The most famous is pituitary adenoma

• What are the symptoms?
• In females: menstrual irregularities, constant presence of milk in the breasts, primary or secondary infertility, low sexual desire.
• In males: primary or secondary infertility, impotence, pathologically increased breast size.
• General symptoms due to direct pressure at the site of the tumor: headache, vomiting tendency, dizziness, disturbance of the field of vision, and other hormonal imbalance.
treatment
• Pregnancy: Pregnancy causes the pituitary gland tumor to shrink.
• Staying away from psychological disorders and stress, because in their presence the secretion of the milk hormone increases.
• Avoiding muscular stress in women.
• Medications: There are drugs that cause the pituitary gland tumor to shrink. Most cases of the pituitary gland leading to increased milk hormone respond to drug therapy.
Surgical intervention: In the event of symptoms resulting from direct pressure on the optic nerve, hypothalamus and vital brain tissues, direct and rapid surgical intervention is recommended.
In the case of surgical intervention, it is microscopic surgery or endoscopic surgery through the nose.

Hydrocele or myelomeningocele
It is one of the common birth defects in our societies. It is usually diagnosed during pregnancy and is dealt with in the first days immediately after birth by doing CT scans and magnetic resonance imaging of the brain and spine. Whereas, based on the results of these tests, the diagnosis is confirmed and treatment methods and priority are determined. It is an opening in the vertebral column, which occurs when the process of closing it is not completed during the stages of embryonic development. Where the membranes surrounding the spinal cord appear outside the open vertebra, and some of the nerve-coated parts of the spinal cord emerge from the back, from the back.
Types of meningocele
1. Meningomyelocele. It is the exit of the contents of the nerve bag represented by the nerve roots with the surrounding membranes from the posterior opening of the affected vertebra. It is possible for this cyst or hydrocele to explode during childbirth with the exit of the cerebrospinal fluid, or the cyst is covered with a dark or incorrect layer of skin.
2. Meningocele. It is the emergence or emergence of a posterior cyst against the incomplete vertebra and it contains cerebrospinal fluid only. Also, this cyst or hydrocele may explode at birth with the exit of the cerebrospinal fluid, or the cyst is covered with a dark or incorrect skin layer.
3. Another case is myeloschisis. A condition in which the back skin components of the spine and the membranes are completely missing, and if we look at the back we see the spinal cord completely exposed.
Consequences of having a meningocytosis
1. Dysfunction in the nervous ability to move the lower extremities
2. Deformation of the feet or legs
3. Weakness or loss of superficial sensation in the lower extremities
4. Poor or no control over the two excreting processes
5. Intellectual performance - In general, most children with unaccompanied myelomeningocele do not have any impairment in mental functioning. But in some cases, a number of them have learning difficulties.
treatment
The obstetrician and gynecologist supervising the birth of such cases calls the neurosurgeon immediately after birth because the incision is open, it is possible for fluids to leak from the brain, and cause pollution in the central nervous system. Therefore, surgery is performed on the child during the first or second day after birth from order to close the incision. During the surgery, the incision in the back is closed, preventing fluid leakage and infection. However, the surgery does not reduce the condition of the paralysis or even the nerve damage that occurs in the part at the level of the incision and below it. It also needs to be followed up by a urologist, as many of these children need a diversion to the urethra. Children with spina bifida can lead normal and active lives. Also, most of them can walk reasonable distances with the help of a leg brace. But most likely these children will also need a wheelchair to get around. The extent of disability is related to the height and position of the affected vertebra.